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EDIT: This answer is long and in parts with additions over time. Please do not confuse this as jumping around and not connected. I’m just not that good of a writer, and am usually very pressed for time and money and do this at a public cafe. One thing has led me to another and without the prior, wouldn’t exist, therefore, I see them as connected.anyone with enough money and a stick up their ass who is connected, because you have to know the right person. What has made a real mess out of this and allowed a few people to hide amongst the masses like the cowardly pieces of shit they are, is societies general consent to throw the rights of a small subset who are simply not prepared or capable to defend themselves against the onslaught which is dropped on them from and by every level and every walk of life, right out the window.So when a handler, the person who receives a usually monthly stipen which has been setup as some type of fiduciary regulated payment, he then uses that at his discretion to encourage or purchase illegal and scandalous, merciless acts perpetrated by a single person or a group against a target as performance on an agreed contract.The handler is usually retired military with some years accrued in the service. They most likely will have seen combat, and or, are recon or people who have been exposed to the intelligence community such as the CIA, sis or mi6, aman or mossad, kgb or east german stasi and are aware or schooled in the tactics of human psychological warfare which they have seen or practiced in live combat situations and which they are willing to use on anyone for a price.The beauty about this is that it only takes one or two individuals and a comparatively, relatively small amount of money to turn an entire community against an individual. These guys will turn otherwise law abiding police officers into their puppets and have them crossing a line they can’t go back over. As a bonus and depending on the handlers political beliefs and agendas, he can work both sides of the coin for the price of one while advancing his political or racial beliefs.And all from the comfort of his Laz-y-boy while hitting the pipe and sipping cognac. I have been observing a seventy year old US Marine Corp combat veteran who was discharged for a mental disability, or so he says, do just this now for about two years. He claims to have been here for the past twenty and his story is confirmed as to length of time.He claims to be receiving benefits from the government, however, I’ve caught him in couple of indiscretions as to his story. So he’s been tripped up but doesn’t know it. Lies in regards to policy and procedure which have no grey area, therefore, that’s a pretty big gap in his cover.Child support, violence against women and sex offenses seem to be the big three as for motives, and, on a scary note. Some of these cases seem to come from men, like an aledged victims father who has passed away and has vowed to strike from the grave as to seeking revenge. Kind of a perfect crime scenario as far as the contractee goes.It would be easy to throw law enforcement up on a cross at this point, however, they know what is going on, but, probably aren’t in a position of making a viable move on this type of activity.But remember, these guys have been used and made fools of. Something they can never change. They’ve for the most part thrown the country’s long standing reputation right down the tubes. Forgotten their sworn oaths. Something they can never take back, and not only have to remember everyday for the rest of their lives, but, even when they look their kids in the eye. That’s got to piss them off like you and I can’t ever imagine.Do you think you’d want these guys on your ass after what has been done to them as payback for the price of their souls?This is as dark and foul as it gets, and, I’ll bet the farm on this one. The people responsible for gang stalking are going to pay.I can’t think of a denial in words equal to the task.addition: this answer is developing on an ongoing real time basis daily. There is a development which is linking gang stalking to trata de blancas, or, white slavery. Human trafficking. This activity is taking place within a few miles of the border in Tijuana/San Ysidro. People long associated with smuggling and the recruitment of “drivers” who as far as I can tell are just being setup for an encounter with waiting CBP. The recruiters are paid pretty well. There is a “boss” who I believe is the liason between the street recruiters and HLS. Furthermore the “boss” has links to the private security industry in the USA, or, maybe even as a police officer, more then likely in Mexico, but, who crosses frequently.Their specialty is deception and betrayal. I can’t see HLS/CBP not being aware of this. Once you get past this deception and what is giving rise to this developement is that an equal goal is defamation and separation based on influence of female counterparts, possibly for the purpose of turning them into sex workers. An interesting statistic I read the other day put sex sales ahead of drugs annually in the USA. If true, there is a pretty great demand for loyal workers.stayed tunedOK, here it goes. Straight the fuck up. 9–10–2019 3:39pm PST.The USA has apparently for a very long time, offered rewards for people giving up people who were “smuggling” contraband into the USA. And, paying pretty good money at that.Now, I’ve been staying in Mexico for eleven years to avoid sleeping on the streets of San Diego. I have been conducting an investigation into problems which beset me many years ago. The following is the product to date of that investigation. The names being used are real as well as the actions and activities described.There are four things which are on and crackin’ at the San Ysidro Port of Entry. Trata de Blancas, sequestradores, robar de infantes and trafficante de organes. Everything ties into these four one way or another. A tangent if you will, but, all connected someway to these four.Then with the influx (segue 1991) of millions of Mexicans flooding the border unimpeded, local businesses found a need for bilingual persons to fill the gaps created by different languages and a need to conduct business and direct employees.All this activity cleared way for always hustle ready Mexicans looking to exploit whoever and whatever they can to the fullest. Being very heirarchy conscious people, bosses or jefes hold a special place or a heavy influence on those who work for them.Herein, lies the story of Enrique. He got his start at the KMart located in San Ysidro, facing Mexico. It’s closed now, but for many years was probably the southern most retailer on the border of that size.Now, Enrique somehow ended up with the job of head security man at KMarts. His specialty was choke holds, something he learned in his days on the streets of Tijuana, running with little 5 man chokeout crews and utilized that tactic in the USA violating the rights of many an American, myself for sure.As he told me, “he didn’t care about my rights and that he had experience and knew people in San Diego law enforcement and would be dealing with us and knew just how to.”The way things work down here is that the men, no matter how dirty, funky or stinking they may be, run and control whoever they can assert power and control over. Tijuana streets tend to be full of poor, unsupervised, orphaned and abandoned people from everywhere all looking to come up, survive, be protected and consume. The bosses look at it like everything they see, they own, so, all these people running around belong to them to do with what they please.Therefore a female, solo, is a prime target for predators like Enrique and his lieutenants like long time associate Yolanda, who is a female Adolph Hitler who enjoys the suffering of others and has found a home under the perpetrations of Enrique who either has a lot of cops fooled in the USA and uses this to operate with impunity, or, there are a lot of corrupt cops working all through the County of San Diego.Don’t get me wrong. Both can be nice people. When they want something or are using you, other then that, forget it.My monies on the later.To give you an idea, Yolanda was stabbed 31 times and left for dead in the local graveyard. She claims the attack was a robbery and one of the guys liked her and she refused to have sex with him, so, he stabbed her 31 times.That’s an awful lot of hate for a robbery. Usually there are two things on the minds of thiefs. Acquire the desired item/s and get as far away as quickly as possible. As an experiment, simulate stabbing your table or desk while counting to 31 allowing for a live, moving, struggling target.Not consistent with the actions of thieves, at least in my opinion.In all fairness, Enrique doesn’t like people to know what he looks like. I’ve seen him three times. Once, he was sitting right next to me at the schools administration office waiting area.I was there to discuss my PELL grant, he was there to talk shit about me to the schools administrators. I would soon have to quit because of what he said to them.After everything had fallen apart in my life and i was trying to get a grip on things, the very first hipothesis I had put together I called it the 180 scenario.All things considered, and using a circle with 360 degrees of separation, travel 180 degrees from wherever you are and that is where you will find the truth concerning whoever or whatever you were seeking.So, if Yolanda presents as a ruthless smuggler coordinator/recruiter whose objective is to recruit Americans south of the border and put them in a car and send them north into what was usually the waiting arms of HLS, flip the script 180 degrees and that is what you are really dealing with.Therefore, If Enrique is this elusive smuggler boss and connect, what he probably is the boss or owner of a private security company/civilian police detail who recruits or enslaves the down and out to carry out his dirty work, while he gets paid. And I don’t believe either of them ever end up sharing any of the money they get. If so, it’s just enough to keep you on the hook.09/12/2019I said this was on an update basis. I got a break today. To everyone who is being gang stalked. Use this template to see how it compares to your situation. I’ve worked a long time to get this. I’ve been shot, beat down 19 times, twice while handcuffed and that’s nothing in the overall.Check this out.Remember the 180 scenario?What if:gang stalking isn’t about coming after you, it’s about keeping you from something.All the bullshit that is thrown at you is to distract you and so that people won’t listen to you even if golden nuggets are falling from your lips.the longer they keep you chasing your tail, the longer they can take what is yours.In attempting to ascertain exactly who or who isn’t reponsible in this is also a waste of time. If you are faced with solving an equation with multiple variables trying to determine the value of x but keep hitting dead ends, then the obvious result can be only one thing…..everybody is guilty.In our case, cops, judges, attornies, family, friends, co-workers…you name it.There are several thimgs that will get you stuck in this rut. For right now, I’m going to use child support. If you don’t pay, you are a piece of shit. Forget that you have just gone through the most gut wrenching thing a person can ever experience, whoever you are. That which is reason for any man or woman to take up whatever is in sight and use that until exhaustion drops you….your family is under attack. Your wife, your kids, your life.You are expected to stand by passively while that which would incite havoc and mayhem in every person on the planet hits you from all sides. Remember, this is all fairly new and in a way we have all taken part in the trial and error process of writing the book on this subject.That doesn’t excuse the actions of our politicians who knew exactly what they were doing.Everybody receives a court order stating custody and support arrangements. For me it was 12.50 a week times two. That’s all they wanted. At one point I had arrears of 3,500 dollars. Then the Clintons enacted legislation which took my arrears from 3500 to 26, 000 dollars and change. Overnite. None of this amount affected or changed my order of support as to how much these kids would receive because there was never an order of modification. That means, 22,500 dollars was going somewhere other than to the kids and was in addition to already well paid persons associated with the administration of child support related activities pay packages.last rough estimate I made had something like 34,000,000,000.00 in unpaid support floating around out there. That’s a lot of money. Using my situation, about twenty percent of that goes to the kids. That means that of the 34b, 7b goes to the kids and 27b is up for grabs.That would explain why cops, lawyers and the like have quit their careers to take up jobs opening companys specializing in support collections.I knew a divorce lawyer in San Diego, Charles Kish, who made a statement one time saying, “I wish I had known before about all the money there is to be made in child support. I wouldn’t be doing divorces.” I didn’t know what he was talking about, but it is starting to make sense.So, anybody with $35.00 can go down to the county clerks office, file a ficticious name, post an announcement in a paper, and, boom, you’re in business.Then all you have to do is start snooping in everyone’s business and find out who is paying or owes child support. Find someone who is in arrears and you can attach yourself like a vampire bat to a fat cow at night. Line up enough of these and you are kickin’ back and watching everyone elses money roll in.If you start to search the lower classes where people are not so well informed you can really make this work. People who can’t afford legal advice and so on.So here is what has been happening to me. Twenty years ago, they took my drivers license in a bizzare surreal court proceeding I doubt was even real. There goes my ability to disappear.Then they attack my abilitiy to make money. The kind they can’t garnish. Plasma donations. Pallets. My own businesses. Then they start to do weird shit like follow me only they make it obvious.What do I do? Start telling people, “hey, I got people following me, like everywhere.” What do they say, “oh yeah? Hmmmmmnnn.” “So how are you doing these days anyway Marcos?”Then they get an abnormal psyche book and go right down the line as to abnormal psychic condtions, enact these little drama theaters for my benefit, and, what do I do?Tell people, “hey, guess what?” The same people I told I was being followed. Now I’m starting to look like a real cracker.Who’s doing it? Advocates. Fatherless kids and their mothers. Sympathizers. The police, collection agents, FOC, Arizona Clearing house. Christian church groups. The Urban League. It becomes a real madhouse with little or no supervision.They are vandalizing my vehicles. One day I went outside to find that my truck had been tampered with. Being from the East Coast, I talk different then these West Coasters.So when I related to my therapist that, “yo, I got people under the hood of my truck,” which to an East Coaster like me means that someone has opened my hood and tampered with things mechanical with the intent of causing damage and/or sabotage and left evidence of such in the aftermath.Now to a West Coast Therapist with a way too tight blouse opened up on top and threatening to shoot the first buttoned button at any second from undue pressure being exerted on it, and a round circle opening between it and the next button down, this means that I believe I have actual little people dwelling under the hood of my truck in the engine compartment causing me mechanical difficulties.“I got people under the hood of my truck,” get it? This is the kind of mixed up problems which have contributed negatively to my efforts oftrying to straighten things out. So what do they do? Give me a brown paper lunch bag full of the best psycotropic narcotics the county has to offer and tell me , “see you in three days,” at which time I get another little lunch bag.One time they gave me Risperdal. I don’t know if I would consider this an ill side eefect, all things considered…but, after taking it a bit, I woke up with an erection that would absolutely not quit. Things was, I couldn’t get off either. My girlfriend didn’t know what to think, thank God or run for her life. In all this went on for eighteen hours and was quite uncomfrtable.We stopped at the Lucky SuperMarket in Lemon Grove. It was summer and I had some shorts on. That was an experience I’m here to tell you. When I went to the clinic the next day, the young lady who was listening to what had happened so as to adjust the medication only had one question, “so was it bulging?”I’m not usually at a loss for words, but, I gotta say I didn’t know what exactly she was asking and wasn’t gonna ask her what she meant.I’ve claimed to be sequestered at various times throughout my ordeal, even called the FBI and said I wanted to report a kidnapping. They asked who the victim was, and I responded it was me. They told me not to call back. I was however, very serious what I was saying, and, rightly so.This is how Yolanda and Enrique get over. He has some kind of criminal justice type connections or business license which enables him to perpetrate these activities.to be continued10/13/2019Yolanda is MIA, that doesn’t mean anything bad or good has happened to her, I just haven’t seen or heard of her for awhile now.As far as who pays these guys goes, right now where I’m at in Tijuana, they are building like crazy. All kinds of people are gone, as in dead, locked up or God only knows. A guy who gave me a ride mentioned something I thought was interesting. He referred to women down here as “broken toys.”Without a doubt, women are at the center of all this “gang stalking” bullshit. Child support, domestic violence and sex offense accusations are used to implement “fabrication of justification” which is how people are getting away with doing what they are doing.For example: If I have no job and live in Mexico and I want to make money and I’m a female who is or isn’t into selling my pussy for money, I become friends with as many single men who live alone as possible. I go by their places and scope it out. Now I always have people backing me up as I’m part of a crew and we tag team people and share information. We know who the crooked cops are and who will let us operate. We stick to Americans and we find out what dirt we can on them and use this to fabricate justification so that when we do our dirt, public opinion doesn’t do us in. We rob people who go to the states everyday and shoplift to survive. Anybody who has or is doing something wrong, we take advantage of that. That way, nobody is going to say anything. We can operate with impunity.It doesn’t matter to them what the circumstances are or even if someone is innocent or not, they fabricate their justification and are off to he races.This is where gang stalking is originating. Cops are supplying the 411 and/or people within the system who work in sub-contracted security jobs are getting it from where they work and using it to line people up and make them targets for these people to live off of without fear of being caught or prosecuted.to be continuedOK 2/26/20 It’s been a few but here it goes. When all this started on me back in 2000, I was taking home $2700 a week, give or take. As my jobs and clients I had in my business dried up due to the relentless non-stop harrassment that plagued me, all my assets and income slid downhill to the point where I had nothing coming in at all. As a result I had to keep finding new ways to make money.This led me to dumpster diving. This led me to conflicts with store employees, security guards and eventually the police. Having no other alternative I thought for years , that I was doing something wrong. In time, as I gathered more knowledge regarding what I was actually doing, I found out that the exact opposite true.I had every right to be where I was, doing what I was doing. I couldn’t believe what I was finding in these dumpsters. Filled, and I mean filled with perfectly good merchandise most of which wasn’t even near the “ëxpiration date.” The only sense I could m,ake out of this was that:No business could throw away the amounts of merchandise in the condition this was in and stay in business for very long, or, who in their right mind would throw obvious profit/money down the drain like this.This merchandise was obviously written off against tax liability to offset the amount of money owed by a corporation in income tax.The IRS didn’t have any field auditors looking in dumpsters and were oblivious to what was going on. They had to be.The reason managers had employees, hired security guards and even police running people off they found looking in dumpsters was 1. they don’t want people to actually become aware of what is actually in there, and 2. they are afraid people will bring it back in the front door for a refund. I mean what good is it to go through all that trouble bilking taxpayers expecting a nice quarterly bonus check to have some bum come back in the front door and negate all your hard work and anticipation?My conclusion was this. Stores use hand held inventory machines to track merchandise. So when they scan this merchandise and devalue it to be written off against their or the manufacturers taxes, take it out back and put it in a dumpster…..whose property is it at that point?Why the taxpayers of the USA, that’s who, and thereby public domain. So to sat that, “no, this is private property,” is a load of bullshit, and, actually opens them up other criminal charges in addition to those they have already committed.Chula Vista, California has a mall located at H street and Broadway. The Mall has a CVS and a Burlington Coat Factory located on the I street side. These guys just love to throw away tons of good stuff so naturally I made this a regular stop.When confronted by mall security, I would just grab my sack full of goodies and walk calmly off the property to the sidewalk where the guards who were dogging me and yelling orders like, “Stop!!” and “put that down,” had to stop because they couldn’t leave mall property.Now I tried informing them of California -v- Greenwood and explaining what was transpiring, but they didn’t care. The obvious next step was threats of calling the police, to which I would stop and tell them, “go ahead, I’ll wait right here.” Which I would do. CVPD would come out and tell me, “no, you’re wrong”amongst other things like, “I’ll arrest you and take you to jail,” to which I would reply, “no you’re not” and this would always turn into an empty threat. I figured I must be right.Well at some point the police must have gotten tired of all the repeated calls by these guys and someone must have given the green light for these guys to physically attack and beat me, and take my belongings.The last two times this happened were pretty serious assault and batteries where one time I seriously had questions as to whether or not I was going to make it. I had four guys on me. One had applied a choke hold and I couldn’t breath. Passers-by called 911.The cops came out and after having me hand cuffed in the back seat and their bodycam rolling, came up to me and wanted me to agree that I was in the wrong and he’d let me go, thereby having a confession of sorts on film. I wouldn’t go along and say what he wanted me to say.So he went over to the guard after telling me and his partner, “we’re going to have to 243 you.” California penal code 243 is battery. So he comes back and informs me I’m being charged on a book and release. They kept my cart and belongings which consisted of a bunch of large bags of M&M’s plain and peanuts.Upon going to court, the prosecutor keeps trying to get me to accept a plea bargain and I keep telling him, “no deals here, my man.” This has gone on for 2 years now, and then the other day I find out I’ve been charged with a felony. A new case where security guards from the same mall say I have taken a defibrulator valued at over $2000 and thereby the charge is grand theft.They say the theft occurred on 09/06/19, they claim to have video of me in the parking lot on 09/08/19, I received mail from local attornies on 09/24/19 offering to represent me on my serious case, but my attorney informs me the prosecutor didn’t file the case until the end of January 2020.Que pedo es esto? Point being, this is how gang stalking works. Police and people with no authority or priviledge to sensitive material can make life real hell on anyone they are so inclined to target.to be continued…26/06/2020Ok, here’s what the past year has brought. Turns out the DA’s tape shows someone who doesn’t resemble me at all, and my attorney has requested a dismissal but has of yet not received a response. The misdemeanor still pends.Looks to me like more tactics to avoid that billion dollar claim filed on 7/22/11. They are trying though. So who employs gang stalkers? Better yet and more direct, “who are gang stalkers?”I’m about 99.97% sure on this. In my situation it came out of Detroit, Michigan as a contract to cover some corrupt activity and keep me down. Iused to think that everyone was “in”on this, but, the way it turns out a very small crew very adept at manipulating the system is responsible, and, make allies out of everyday people through lies they perpetrate to the police, courts, the DMV, MADD, VAWA advocates….anyone who can be counted on to act and react in a normal fashion expected from persons who work at all the desired positions and are normal exhibitors of human nature.Those feelings and emotions which are embedded in us all and elicit elevated emotional responses to specific stimuli introduced into a controlled environment to the unwitting accomplice by a special interest manipulator with knowlwedge and intent to subject the target to an unlimited amount of possible violations restricted only by the accomplices imagination and moral and ethical boundaries. The sim knows full well that the accomplice is going to react.The best part of this is he doesn’t have to pay or come into direct contact with the person(s) and has an army of possible “helpers” at his disposal.And, he doesn’t mind using others in any capacity.Gang Stalking is real. Gang Stalking is as ugly as it gets. It has permitted a lot of people supposedly clean righteous and pious pillars of society to cross a line they can never go back across.It’s like the devil showed up one day and snatched an unbelieveable number of souls in a very short time, and, everyone who no longer has a soul still want to stand around and act like they do. Well, the joke’s on you.People might talk and think a lot of shit about me, and, I may be part of a vastly small minority……………….but I still got my soul. And you?END

Well, you didn’t feel like asking a small question, did you? This is one of the biggest I’ve ever seen, and I’m keen to take a stab at it.I’m a Canadian, by the way, although I’ve spent years working for several branches of the American Armed Forces. Here’s my take on how your proposal - strictly a thought exercise for the fun of it, of course - could go down.Full disclosure - I am firmly against military adventurism of any kind, by anybody. Fun to fantasise about if you’re into that, horrible for real human beings and an obscenity that our planet has had more than enough of. (Putin, Xi, and Trump, I’m looking at you.)Why would Americans want to “conquer the world”? A small number of billionaires might be on board so they could get richer. But most would want to bring their way of life, system of government, and all those rights and freedoms, to everyone. Not the worst motivation, even if its for a horrible idea. Pictured is the US Department of Justice building, one of many government agencies that would have to take on massive new responsibilities if the US moved to rebuild all nations in its own image.On with the world conquest. But what I am going to lay out for you is not quite the universal bloodbath envisioned in the question, but the conquest of American values, applied evenly across the entire globe, and the mandatory participation of all nations forced in the mid to late 1940’s, when US hegemony was complete.Only the Soviets would have been likely to resist, but if their hand were forced immediately with the threat of nuclear weapons, even they could be compelled to cave and give up Communism. It very likely would be quite ugly, but if only the US had the bomb, it’s hard to see how the Soviet Union could do anything other than capitulate, or voluntarily cease to exist other than as a nuclear wasteland.(I’m not saying this would have been a wise, just, or moral course by the US; it’s just what it would have taken. Read on and decide for yourself whether or not the end would have justified the means.)In early 1945, when it was clear that the Allies were going to win an overwhelming victory, the United States called a meeting with its closest ally, Great Britain.US: We want to conquer the entire world.UK: Jolly good! We’ve been there, done that, got the Nehru jacket. And we’ll be pleased to cooperate and advise as necessary. If you like, we can manage the effort. When do we start?US: Well, we mean the entire world, including you.UK: Ah. Fair enough. What is it that you’re after, exactly?US: We want liberty and justice for all. *clears throat nervously* Representative government, all children get an education, access to medical, dental, and vision care. No more dictators, warlords, or official corruption. Better roads, railroads, shipping, and air transportation. Religious freedom. The right to work. Easy trade and immigration with reduced barriers and tariffs. Basically, we want to raise the standard of living across the entire globe by instituting the norms and standards that we are SURE work the best: ours.UK: That’s very commendable. Are you aware we have all that already in the UK, as well as in our overseas territories, possessions, colonies, and of course our dominions, such as Australia and Canada?US: You do? Well, it would save us a lot of time and trouble if we didn’t actually have to fight you and invade and whatnot.UK: A reasonable attitude. Perhaps we can draw up a joint declaration to be binding on all nations. And if we make it a positive statement - reaffirming the dignity of all men and women, that sort of thing - community of nations, shared values, rising tide lifts all boats -US: Okay. Um, would you be willing to write up a draft for our president to sign?On April 29, 1945, US troops liberated thousands at Nazi Germany’s Dachau concentration camp. After seeing the worst the rest of the world had to offer, Americans may be forgiven for thinking that their system and way of life was the best, and ought to be spread to other nations, by hook or, if necessary, by crook.Thus came about the Statute Of Liberty. [First Draft follows.]To all nations, hear ye!Bells are ringing.The bells toll for an end to the present war, and to all future wars.The bells toll for the Four Freedoms:Freedom of Speech,Freedom of Religion,Freedom from Want,Freedom from Fear.We, the human race, stand at a crossroads. We have harnessed the power of the atom and this day, we have the power to end our own existence - to snuff our out species and leave our world a dead, burnt husk.Because of this sobering fact, we will provide today for all freedoms to be globally enacted, except one:the Freedom to Fail as a Planet.For this reason, we, the United States of America, do hereby declare on behalf of all peoples the world over that we shall act as agents for all, and compel all national governments to submit to this Statute of Liberty, the provisions of which Statute are as follows:1.0. In each nation, executive, legislative, and judicial systems shall be modeled after the US (for Republics) or the UK (for Constitutional Monarchies). A written Constitution modeled after the US Constitution, and a Bill of Rights modeled after the US Bill of Rights, shall be required (timetable for drafts, approval, and enactment in appendices.)1.1. The goal is to establish just, accountable, and representative government of, by, and for the people, with standards and norms to be implemented in common across the entire world. These standards and norms are those that have been tried and proven in the crucible of world war. They shall be enforced upon all nations, by goodwill where possible and, regrettably, by proportional military intervention where necessary, in order to advance the rights, freedoms, safety, and prosperity of all humanity.1.1.1. The Period of Transition from current government and military structures to compliant structures shall be four years (per Appendices.)1.2. Control: The US shall appoint to each nation a Governor-General and staff, initially consisting of the current Embassy staff. All officials and bodies of the host nation government shall be answerable to the Governor-General, whose conduct, powers, responsibilities, and limits are established in the Appendices. (Procedures for UK and British Commonwealth nations, other exceptions, per Appendices.)2.0. The military apparatus of each nation shall be responsible to the designated authority. This authority shall be a US-appointed Officer answerable to the Department of Defence in Washington, DC. (Procedures for UK and British Commonwealth nations, other exceptions, per Appendices.)2.1. The goal is to eliminate war while providing fiscally responsible security for citizens, trade, and commerce of each nation. Central management and oversight above the national level are the means to achieve these goals.2.2. Military budget, force size and composition, basing, training, and all other functions to be determined and executed by national government, subject in all particulars to approval authority of US Military Attache. Basis shall be regional and global planning coordinated by US Department of Defence on behalf of all nations. (UK and British Commonwealth provisions per Appendices.)3.0. Requirements:Each nation is directed to enact all of the above provisions in accordance with attached timetables, as well as the following:3.1. A fair and just system of taxation and fees to raise revenue for the operation of the several duties of the government, within guidelines in Appendices;3.2. A universal and compulsory system of public education for children through 12 years of school, the curriculum to be subject to approval of the Governor-General;3.3. A system of post-secondary education to include universities, trade/technical schools, engineering schools, medical schools, etc. as per Appendices, with all curricula subject to approval of the Governor-General;3.4. A national system to adopt, enact, and enforce international standards for construction, engineering, and safety standards (exceptions permitted with approval of Governor-General);3.5. A national system of hospitals and clinics, operated jointly with medical schools, to provide high quality health care that is available to all (operations and budget subject to approval by the Governor-General).3.6. A national electrification and communications plan (“plan” defined fully in Appendices, but includes a written plan to be updated annually for 10 years, biennially thereafter, with a government agency, ministry, department, bureau, office, etc. charged with its administration, per national constitution);3.7. A national transportation plan (may be separate plans for land, air, and/or ports and waterways as required, by approval of the Governor-General);3.8. A national water resources plan (includes potable, non-potable, and irrigation water treatment and distribution systems and standards);3.9. A national agricultural resources plan (includes standards for agricultural practices, irrigation, use of fertilisers/pesticides, food distribution, sale, inspection, and safety, other provisions per Appendices);3.10. A national industrial and labour policy plan (includes support for industries, labour & employer rights & responsibilities, minimum wages by profession, etc.) by approval of the Governor-General;3.11. A national parks, museums, reserves, preserves, and recreational areas plan;3.12. And other plans as per Appendices. (Note all plans and administering departments, ministries, and/or agencies to be based on provided templates and subject to approval of Governor-General).4.0. International disputes to be arbitrated by US State Department or delegated agencies.4.1. An international body to be convened once 50% of the nations have adopted this Statute, location and procedures per Appendices. This body to discuss and propose to US Government possible amendments, additions, changes, and deletions to provisions of this Statute, other business as necessary.5.0. All nations are required to approve all provisions of this Statute and enact requirements per timetable in Appendix (in general, draft within two years of enactment date, review and comment by Office of Governor-General, with revised and completed Constitution/Plans etc., four years from enactment date.)5.0.1. All nations shall be evaluated and graded on adoption and adherence to this Statute on a rolling four-year schedule per Appendices. National jurisdiction and self-government shall be privileges, linked to the nation’s grade and position in one of five classes (per Appendices; updated annually).5.1 The goal is to place all nations on the road to providing standard governance to their citizens/subjects in accordance with the demonstrated best practices and norms as established in this Statute for the advancement of all humanity, the management of disagreements and disputes with impartial justice and without resort to violence, and the establishment and enforcement of basic human and civil rights for all people without exception due to race, religion, national origin, language, ethnicity, or gender.5.2. The adoption of this Statute is mandatory and will be enforced if necessary by the full weight and power of the United States of America and/or delegated nations.[END FIRST DRAFT]There you have it - every nation in the world essentially forced to rewrite its government and adopt a US-style constitution and bill of rights, and a full suite of governmental agencies/ministries on the US model, on pain of US military intervention.Military affairs basically decided by the US on behalf of the nations.All that should satisfy the war hawks, but ideally, most of the world will agree to the new system with no need for force. To the war hawks, this means they ‘conquered’ these nations; to those nations themselves, they voluntarily joined an international effort to prevent such a war from ever happening again.Where’s the rub? With nations that say no. What happens next?Probably the detonation of a nuclear device, preferably over a remote military installation to minimise deaths and damage, would be sufficient. But the US will be pretty committed at that point, and if (say) the USSR declined repeatedly, it would have to keep nuking larger targets until the nation capitulated.Ideally, once all nations had been persuaded or coerced into signing the Statute, the US would then be able to supervise their military establishments and prevent them from building nukes.Who knows? If the Soviets had capitulated without the need for a horrific nuclear demonstration, the world might well have entered a new golden age. More likely, I wonder whether the perceived tyranny and loss of sovereignty in every country wouldn’t have invited passive and active resistance, assassinations, destruction of property, and - with a likely US overreaction here and there - a general rebellion that would have ultimately forced an America haemorrhaging blood and treasure to give up its ambitions of formal hegemony and return to the stealthier modes - Cola conquest, dollar domination, and the sexy tyranny of blue jeans and rock and roll.

Physiotherapy ManagementPrecautions and ContraindicationsPatients are at risk of hip dislocation after replacement as a result of the trauma to the hip stabilizers of the hip (capsule, ligaments and muscles) as well as due to the size difference of the prosthesis to the bones. Reduced size of the prosthetic femur head when compared to the average human femur head makes it easier to dislocate until the stabilizing tissues have healed and adapted to this smaller size[40]. This generally takes up to 6 weeks to heal.Posterior ApproachNo combination of the following hip movements on the operated side:Flexion > 90 degreesInternal rotation past neutralAdduction past midlineWeight bearing restrictions as per surgeon (mostly partial to full weight bearing for 6 weeks after surgery)Anterior ApproachHip replacements following this surgical approach is generally more stable. No specific ranges are currently linked to the precaution movements, as surgeon preference should also be taken into account.Patients are encouraged to avoid a) excessive ranges and b) combination of the following hip movements on the operated side:ExtensionAbductionExternal rotationWeight bearing restrictions as per surgeon (usually less strict than with posterior approach surgery and patients are able/allowed to mobilise unaided sooner)Pre-operativePrescribing preoperative exercise as soon as people are approved for hip surgery could play an important role towards improving preoperative quality of life, because people can wait many months for surgery and might experience further deterioration in health-related quality of life during long waits.[41] Level 2b evidence shows that physiotherapy and educational therapy may be useful for end-stage osteoarthritis.[42] A study on a 6 week education and exercise programme has shown significant and sustained improvements in pain and disability on patients wait-listed for joint replacement surgery. Further positive results included improvements in function, knowledge and psycho-social aspects.[43]A pre-operative assessment and treatment session is very helpful in the planning of the post-operative management of patients following a total hip replacement. Benefits include decreased length of stay[44],decreased anxiety levels[45], improved self-confidence[46] and establishing a relationship of trust between the physiotherapist and patient early on. Further benefits include improved quality of life and psychological health.[45] It also helps to develop a patient-specific rehabilitation programme to follow post-operative, taking assessment findings into consideration. The main factors defining the therapy management are the surgical approach and the general state of the patient. Whether the patient desires to gain physical fitness or wishes to recover for recreational activity should also be taken into account when establishing the rehabilitation programme.Research has shown that a combination of verbal explanation and written pamphlets is the best method for health education.[45] It is very important to incorporate this into the pre-operative physiotherapy management of patients prior to total hip replacements. Pre-operative education on precautions are liked to better post-operative adherence.[45]AssessmentSubjective historyRange of motionMuscle powerCirculationMobility and function[46]TreatmentEducation and advice:Patient information bookletPrecautions and contraindicationsRehabilitation processGoals & expectationsFunctional/ADL adaptionsSafety principlesEncourage to stop smoking if applicableDischarge planningTeach:Bed exercisesTransfers in and out of bed (within precautions)Gait re-education with mobility assestive device (crutches vs walking frame vs rollator)Stair climbingPost-operativeThe aim of post-operative rehabilitation is to address the functional needs of the patient (e.g. start mobilising) and to improve strength and range of motion. This starts off as an assisted process, but the aim is to get the patient as functional as possible prior to discharge. As a result of the underlying pre-operative pathology, patients may present with muscle atrophy and loss of strength, particularly in the gluteus medius and quadriceps muscles. The result of the loss of strength is that the elderly are less independent.[8] Although the surgery will correct the joint problems, any associated muscle weakness that was present before the surgery, will remain and require post-operative rehabilitation. Research has shown hip abductor weakness after surgery is a major risk associated with joint instability and prosthetic loosening.[9] Early postoperative rehabilitation after a total hip replacement focuses on resorting mobility, strength, flexibility and reducing pain.[10] It is found that patients can achieve significant improvements through a targeted strengthening programme following total hip replacement.[47]No specific general hip replacement protocol is currently in use, as small elements of the rehabilitation process is surgeon specific. For example, in some enhanced recovery after surgery protocols, patients are mobilised out of bed within the first 6 hours post surgery. Other settings may only start mobilising patients out of bed on day 1 or 2 post surgery. Accelerated rehabilitation programmes and early mobilisation have shown to give patients more confidence in their post-operative mobilization and activities of daily living, as well as being more comfortable with earlier discharge.[48]EvidencePhysiotherapy can improve strength and gait speed after total hip replacement and help prevent complications such as subluxation and thromboembolic disease. In addition, physiotherapy increases the patient’s mobility and offers education about the exercises and precautions that are necessary during hospitalization and after discharge.[49] (level of evidence 1a)Physiotherapy maximizes the patient’s function which is associated with a greater probability of earlier discharge, which is in turn associated with a lower total cost of care[50](level of evidence 2c).Physiotherapy provides pain relief, promotes rehabilitation and the reintegration of patients into ADLs. It also provides a better quality of life through the patients’ reintegration into social life [51] (level of evidence 1b).Level 1b evidence suggests that bed exercise following a total hip replacement does not seem to have an effect on the quality of life[52], but stays important for the effects on oedema, cardiac function and improving range of motion and muscle strength (level 4 evidence).[53]. It also allows an assessment of the physical and psychological condition of the patient right after surgery.Early weight bearing and physical activity has benefits for the quality of bone tissue[32] as it improves the fixation of the prosthesis and decreases the incidence of early loosening. The amount of activity is patient specific, and clinical reasoning should be used to make adaptions where needed. Certain specific sport movements have a higher risk of injury for unskilled individuals, and should be incorporated later in the rehabilitation process under supervision of a physiotherapist or biokinetisist.The following is a suggested protocol in the absence of complications. Surgeon preference should be taken into account, as well as any other factors that might hinder the following of the protocol. Adaptions should be made to make it more patient specific.[46][54]Day 1 Post-SurgeryEducation and adviceEducation of muscular relaxationRevision of precautions and contraindications (provided that patient had a pre-operative session with the physiotherapist, otherwise full education will be done as mentioned in pre-operative section).Bed exercises:Circulation drillsUpper limb exercises to stimulate the cardiac functionMaintenance of the non-operated leg: attention should be paid to the range of motion in order to preserve controlled mobilisation on the operated hipIsometric quadriceps (progressing to consentric VMO) and gluteal contractionsActive-assisted (progressing to active) heel slides, hip abduction/adductionBed mobilisation using unilateral bridging on the unaffected legTransfer to sit over edge of bedSit to stand with mobility assistive device (preferably a device giving more support like a walking frame or rollator)Gait re-education with mobility assistive device as tolerated (weight bearing status as determined by surgeon)Sitting out in chair for maximum 1 hourPostioning when transferred back to bedDay 2 Post-SurgeryBed exercises as described above, progressing repetitions and decreasing assistance given to patientProgression of distance mobilised and/or mobility assistive deviceIncorporate balance exercises if neededSitting in chairDay 3 Post-SurgeryBed exercises as described above, progressing repetitions and decreasing assistance given to patientProgression of distance mobilised and/or mobility assistive deviceStair climbing (at least 3, or as per home requirements)Sitting in chairRevision of precautions, contraindications and functional adaptionsGive 6 week progressive resistive strengthening home exercise to patient; this can include stationary cycling, as long as the patient stays within the precautions (especially posterior approach surgery)Discharge from hospitalAccelerated ProtocolCombination of day 2 & 3 to discharge patient day 2 post surgery.Only selected patients6 Weeks Post SurgeryPatients are normally followed up by orthopaedic surgeonSurgeon determine if the patient are allowed the following:Full range of motion at the hipFull weight bearing without mobility assistive deviceDrivingAfter 6 WeeksGain of initial ROM, stabilization, and proprioceptionEnduranceFlexibilityBalanceSpeed, precision, neurological coordinationFunctional exercisesOutcome MeasuresHarris Hip ScoreOxford Hip Score (OHS)6 Minute Walking TestTimed Get Up & Go TestWestern Ontario and McMaster universities osteoarthritis index (WOMAC)SF-36Fear Avoidance Belief ScoreHip Disability & Osteoarthritis Outcome Score (HOOS)International Hip Outcome ToolIbadan Knee/Hip Osteoarthritis Outcome MeasureTake Home MessageProper preoperative examination and early postoperative rehabilitation is crucial for successful outcome.ResourcesPre-operative patient workbook on "living with osteoarthritis"Related articlesTotal Knee Arthroplasty - PhysiopediaDefinition/Description Total knee arthoplasty (TKA) or total knee replacement (TKR) is a orthopaedic surgical procedure where the articular surfaces of the knee joint ( the femoral condyles and tibial plateau) are replaced. There is at least one polyethylene piece, placed between the tibia and the femur, as a shock absorber.[1] In 50% of the cases the patella is also replaced. Reasons for a patella replacement include: osteolysis, maltracking of the patella, failure of the implant. The aim of the patella reconstruction is to restore the extensor mechanism. The level of bone loss will dictate which kind of patella prosthesis is placed. [2] The main clinical reason for the operation is osteoarthritis with the goal of reducing an individuals pain and increasing function..[3] Clinically Relevant Anatomy The Knee is a modified hinge joint, allowing motion through flexion and extension, but also a slight amount of internal and external rotation. There are three bones that form the knee joint: the upper part of the Tibia , the lower part of the Femur and the Patella. The bones are covered with a thin layer of cartilage, which ensures that friction is limited. On both the lateral and medial sides of the tibial plateau, there is a meniscus, which adheres the tibia and has a role as a shock absorber. The three bones are kept together by the ligaments and are surrounded by a capsule. Epidemiology /Etiology When all the compartments of the knee are damaged, a total knee prosthesis may be necessary. The most common reason for a total knee prosthesis is Osteoarthritis [4]. Osteoarthritis causes the cartilage of the joint to become damaged and no longer able to absorb shock. There are a lot of external risk factors that can cause knee osteoarthritis. For example: being overweight; previous knee injuries; partial removal of a meniscus; [5] rheumatoid arthritis; fractures; congenital factors. There might also be some genetic factors the contribute to the development of osteoarthritis, but more research is necessary. Total knee arthroplasty is more commonly performed on women and incidence increases with age.[5] IN the US in 2008 63% of TKR operations were on women. Also a dramatic increase in TKR surgery is projected to occur with a 673% increase by 2030 in America..[6] Another trend for TKR surgery is the increasing rate of of recipients under 60, whilst initially designed as an operation for the >70 age bracket.[7] Characteristics/Clinical Presentation Pain is the main complaint of patients' with degenerated knee joints. At first, pain is felt only after rest periods ( this is also called ‘starting pain’) after a couple of minutes the pain slowly fades away. When the knee joint degeneration increases, the pain can also occur during rest periods and it can affect sleep at night. Individuals' can also complain of knee stiffness and crepitus. Due to pain and stiffness, function can decline and is manifests as reduced exercise tolerance, difficulty climbing stairs or slopes, reduced gait speed and increased risk of falls. Complications Stiffness is the most common complaint following primary total knee replacement, affecting approximately 6 to 7% of patients undergoing surgery.[8] *0 5 of patients have some degree of movement limitation.[6]In addition to stiffness, the following complications can impact on function following this surgery: Loosening or fracture of the prosthesis components Joint instability and dislocation Infection Component misalignment and breakdown Nerve damage Bone fracture (intra or post operatively) Swelling and joint pain Complications as above may require joint revision surgery to be performed. Diagnostic Procedures In order to assess the gravity of wear or injury the orthopedic surgeon carries out external tests, and the patient is likely to undergo imaging. Patients co-morbidities also need to be considered[9] Obesity is an important factor that needs to be considered prior to surgery as evidence suggests a correlation between higher body mass index (BMI) and poorer post-operative functional outcomes [10] These are the different stages of osteoarthritis that you can see at a MRI. Outcome Measures Knee disability and Osteoarthritis Outcome score (KOOS) The Timed Get Up and Go Test (TUG) Visual Analogue Scale (VAS) Range of motion (ROM) [11] Examination Subjective Assessment First the examiner should ask the patient about the history of complaints and also about expectations from surgery. The examiner should then perform a full objective examination. After this different tests could be carried out to determine whether the patient needs total knee arthroplasty: Active ROM Passive ROM Muscle power Functional tasks Post-operative Tests Inspection: of the wound/scar, redness, adhesion of the skin. When infection of the wound is suspected the patient must be referred to an Orthopedic Consultant or an emergency doctor. Palpation: post-operative swelling, hypertonia (adductors), pain and warmth. [12] Medical Management The purpose of the surgical procedure is to achieve pain free movement again, with full functionality of the joint, and to recreate a stable joint with a full range of motion. Total knee arthroplasty is chosen when the patient has serious complaints and functional limitations. Surgery takes some 60-90 minutes and involves putting into place a three-part prosthesis: a part for the femur, a part for the tibia, a polyethylene shock absorbing disc and sometimes a replacement patella. A high comfort insert design is chosen to achieve this. The perfect prosthesis doesn’t exist; every prosthesis must be different and the most appropriate size and shape is chosen on a patient by patient basis. During surgery a tourniquet is sometimes used; this will ensure that that there is less blood loss. However, when a tourniquet is not used, there will be less swelling and less pain.[13] Physical Therapy Management Pre-operative The physical therapist can choose to teach the patient the exercises before surgery in order that the patient might understand the procedures and, after surgery, be immediately ready to practice a correct version of the appropriate exercises. It is also important that the functional status of the patient before surgery is optimised to assist recovery. The focus of a pre-operative training program should be on postural control, functional lower limb exercises and strengthening exercises for both of lower extremities.[14] Unfortunately, there is limited evidence to support that pre-operative physiotherapy brings significant improvements in patient outcome scores, lower limb strength, pain, range of movement or hospital length of stay following total knee arthroplasty.[15] Post-operative Evidence indicates that physiotherapy is always beneficial to the patient post-operatively following total knee arthroplasty. Although specificity of intervention can vary, the benefits of the patient actively participating and moving under physiotherapists' direction are clear and supported by the evidence. There is also some low-level evidence that accelerated physiotherapy regimens can reduce acute hospital length of stay.[16] Perhaps the most important role of physiotherapists in the management of patients following TKA is facilitating mobilisation within 48 hours of surgery, sometimes as early as the same day as the operation (Day 0). The use of a continuous passive motion (CPM) may be utilised in this period. A 2011 report found that although clinical outcome measure showed no better results than traditional mobilisation techniques, subjectively patient outcomes of pain, joint stiffness and functional activity were better.[17] The optimal physical therapy protocol should also include strengthening and intensive functional exercises given through land-based or aquatic programs, that are progressed as the patient meets clinical and strength milestones. Due to the highly individualized characteristics of these exercises the therapy should be under supervision of of a trained physical therapist for best results. [18] [19] There is evidence that cryotherapy improves knee range of motion and pain in the short-term. With are relatively small sample size of low quality evidence, it is difficult to draw solid conclusions regarding the outcomes measured and specific recommendations cannot be made about the use of cryotherapy.” [20] Common Bed and Chair Exercises [21] Ankle plantarflexion/dorsiflexion Isometric knee extension in outer range Inner Range Quadriceps strengthening using a pillow or rolled towel behind the knee Knee and hip flexion/extension Isometric buttock contraction Hip abduction/adduction Straight leg raises BridgingPartial Knee Replacement - PhysiopediaDescription A partial knee replacement (PKR) is a surgical procedure to replace only one part of a damaged knee. It can replace either the inside (medial) part, the outside (lateral) part, or the kneecap (Patellofemoral) part of the knee. With PKR, only the damaged area of the knee joint is replaced, which may help to minimize trauma to healthy bone and tissue, and also helps relieve arthritis in on or two of the three compartments of the knee. Surgery to replace the whole knee joint is called total knee replacement. Indication Partial Knee Replacement is intended for use in individuals with joint disease resulting from Degenerative, Rheumatoid and post-traumatic arthritis, and for moderate deformity of the Knee. Clinical Presentation People with advanced osteoarthritis and conservative treatments have been exhausted.[1] Mild valgus or varus deformity. Pain is often noted when performing physical activities requiring a wide range of motion in the knee joint.[2] Diagnostic Tests X-ray and MRI of the joint will reveal the joint disease resulting from Degenerative, Rheumatoid or any Post traumatic arthritis, and also moderate deformity of the Knee. The x-ray indication for a knee replacement would be weightbearing x-rays of both knees- AP, Lateral, and 30 degrees of flexion. AP and lateral views may not show joint space narrowing, but the 30 degree flexion view is most sensitive for narrowing. If this view, however, does not show narrowing of the knee, then a knee replacement is not indicated. Surgical Procedure & Types of Partial Knee Replacement Types MEDIAL PATELLOFEMORAL LATERAL BICOMAPRMENTAL Unicondylar Knee Replacement is a procedure that replaces only the single affected compartment of the knee, either the medial or lateral compartment. Patellofemoral Knee Replacement is a procedure that replaces the worn patella (the kneecap) and the trochlea (the groove at the end of the thighbone). Bicompartmental Knee Replacement is a procedure that replaces two compartments of the knee, the medial and patellofemoral compartments. Pre-operative Preparation Pre-operative preparation begins immediately following surgical consultation and lasts approximately one month. The patient is to perform range of motion exercises and hip, knee and ankle strengthening (Isometrics) as directed by Therapist. Before the surgery is performed, pre-operative tests are done: usually a complete blood count, electrolytes, APTT and PT to measure blood clotting, chest X-rays, Electrocardiogram, and blood cross-matching for possible transfusion. About a month before the surgery, the patient may be prescribed supplemental iron to boost the hemoglobin in their blood system. Accurate X-rays of the affected knee are needed to measure the size of components which will be needed. Medications such as warfarin and aspirin will be stopped some days before surgery to reduce the amount of bleeding. Patients may be admitted on the day of surgery if the pre-op work-up is done in the pre-anesthetic clinic or may come into hospital one or more days before surgery. Some hospitals offer a pre-operative seminar[3] for this surgery. Currently there is insufficient quality evidence to support the use of pre-operative physiotherapy in older adults undergoing total knee arthroplasty[4] Preoperative education is currently an important part of patient care. There is some evidence that it may slightly reduce anxiety before knee replacement surgery, with low risk of detrimental effects.[5] Weight loss surgery before a knee replacement does not appear to change outcomes.[6] Post-operative Rehabilitation The length of post-operative hospitalization is 5 days on average depending on the health status of the patient and the amount of support available outside the hospital setting.[7] Protected weight bearing on crutches or a walker is required until specified by the surgeon [8] because of weakness in the quadriceps muscle[9] To increase the likelihood of a good outcome after surgery, multiple weeks of physical therapy is necessary. In these weeks, the therapist will help the patient return to normal activities, as well as prevent blood clots,improve circulation,increase range of motion,and eventually strengthen the surrounding muscles through specific exercises. Week 1 Goals Decrease pain/swelling. Passive range of motion <90 degrees (secondary to stitches) x 2 weeks. Full weight bearing. Week 2 - 4 Goals Decrease pain/swelling. Tolerate bilateral stationary cycling. Active range of motion 0-90 degrees. Week 4 - 6 Goals Normal gait pattern. Week 6 - 8 Goals Active range of motion 0 to 110 degrees. Passive range of motion 120 degrees. Week 8 - 12 Goals Road cycling. Walk downstairs with reciprocal gait. Full range of motion.[10] Treatment includes encouraging patients to move early after the surgery. [11] Often range of motion (to the limits of the prosthesis) is recovered over the first two weeks (the earlier the better). Over time, patients are able to increase the amount of weight bearing on the operated leg, and eventually are able to tolerate full weight bearing with the guidance of the physical therapist. After about ten months, the patient should be able to return to normal daily activities, although the operated leg may be significantly weaker than the non-operated leg.[12] For knee replacement without complications, continuous passive motion (CPM) can improve recovery. [13]Additionally, CPM is inexpensive, convenient, and assists patients in therapeutic compliance. However, CPM should be used in conjunction with traditional physical therapy. In unusual cases where the person has a problem which prevents standard mobilization treatment, then CPM may be useful. Contra-indications & Common Side-Effects Key Evidence Some physicians and patients may consider having lower limbs venous ultrasonography to screen for deep vein thrombosis after knee replacement.However, this kind of screening should be done only when indicated. If a medical condition exists that could cause deep vein thrombosis, a physician can choose to treat patients with cryotherapy and intermittent pneumatic compression as a preventive measure.[14] Partial Knee EReplacement surgery is not appropriate for patienst with certain types of Infections, any mental or Nueromuscular disorder which would create an unacceptable risk of prosthesis instability, prosthesis fixation failure or complication in postoperative care, skeletal immaturity, severe instability of the knee or Excessive body weight. Comom side effects:as with any surgery, PKR has its risks which may be Implant related risks which may lead to a revision include dislocation, loosening, fracture, nerve damage, heterotropic ossification, wear of the implant, metal sensitivity, soft tissue imbalance, osteolysis(localized progressive bone loss) and reaction to particle debris. Knee implants may not provide the same feel or performance characteristics experienced with a normal healthy joint.Partial Hip Replacement - PhysiopediaDescription Partial Hip Replacement is a surgical procedure used to replace half of the hip joint. The operation involves replacing the ball of the femur that has worn from arthritis, degeneration, or a serious fracture involving the ball of the hip joint. Normal motion becomes restricted and painful with advanced wear of the hip joint.[1] Indication A fractured neck femur, where the fracture occurs just below the ball-and-socket hip joint causing the ball to get disconnected from the rest of the thigh bone or femur. Blood supply to the fractured portion of bone is often disrupted at the time of injury and is at high risk of not healing when the fracture is badly displaced. Osteoarthritis: the degeneration of cartilages located at the end of the hip bones. Rheumatoid arthritis: the inflammation of the synovial membrane in the hip joints causing abnormal production of synovial fluid. Traumatic arthritis, from hip fracture or severe hip injury. Avascular necrosis where the head of the femoral bone dies due to lack of blood supply, and many other degenerative diseases are also factors that lead to broken the head of femur.[2] Note: [Partial hip replacement is only recommended on occasion and generally when the patient is elderly and in poor health, because metal prosthesis bearing against bone is not the optimal solution. It can result in wear on the bone and possibly even to the point of wearing away the base of the socket. For this reason, certain patients (young and very able and active older patients) may have a total hip replacement.][3] Clinical Presentation add text here relating to the clinical presentation of the condition Diagnostic Tests add text here relating to diagnostic tests for the condition Pre-Op add text here relating to the pre-operative advice Post-Op add text here relating to post-operative rehabilitation Key Evidence add text here relating to key evidence with regards to any of the above headings Resources add appropriate resources here Case Studies add links to case studies here (case studies should be added on new pages using the case study template)Total Ankle Arthroplasty - PhysiopediaWhat is an Ankle Arthroplasty? Ankle arthroplasty is when the ankle joint (Talocrural Joint) is replace with prosthetic components comprised of polyethylene and metal and is preferred to ankle arthrodesis (fusion) as range of movement and function an not compromised. Main objectives of the arthroplasty are to Replicate ROM of the talocrural joint Function well under weight bearing Be wear resistent Maintain alignment and stability History of Total Ankle Arthroplasty Ankle replacement surgery has been available for over two decades however it is a far less common procedure than hip or knee arthroplasty owing to the less frequent incidence of osteoarthritis ankle pathology. The majority of ankle osteoarthritis is secondary to trauma.[1] Until relatively recently, ankle joint arthrodesis (fusion) was the gold standard of treatment, but this was not without its complications, e.g. non-union, osteoarthritis in the other mid/hind foot joints and stiffness and loss of proprioception[2] Total ankle replacement was developed in the 1970's but initially was plagued with high long term failure rates. The older prosthesis loosened or malfunctioned and frequently needed to be removed[3]. In the late 70's Dr. Frank G. Alvine an orthopedic surgeon from Sioux Falls, SD developed the Agility Ankle which was the first FDA approved total ankle implant in use in the United States[4]. Since its introduction the Agility Ankle System has gone through several modifications. Currently the Agility Ankle System is the most widely used ankle prosthesis. With more than 20 years of experience it has the longest followup of any fixed bearing device[5]. On May 29, 2009 the medical news today announced the FDA approved the first mobile bearing device called the Scandinavian Total Ankle Replacement System (STAR). As a condition of FDA approval the company (Small Bone Innovations Inc.) must evaluate the safety and effectiveness of the device during the next eight years[6]. In a systematic review of the literature published in the Journal of Bone and Joint Surgery in 2007, the intermediate outcome of total ankle arthroplasty appears to be similiar to that of ankle arthrodesis however data was sparse[7]. In a study comparing reoperation rates following ankle arthrodesis and total ankle arthroplasty SooHoo, Zingmond and Ko confirmed that ankle replacement is associated with a higher risk of complications as compared with ankle fusion, but also has potential advantages in terms of a decreased risk of the patient requiring subtalar joint fusion[8]. In a seven to sixteen year follow up on the Agility Total Ankle Arthroplasty, Knecht, Estin, Callagham et al concluded that the relatively low rates of radiographic hindfoot arthritis and revision procedures at an average of nine years after the arthroplasty are encouraging[9]. Although interest in total ankle replacements is increasing, midterm clinical results to date are few and often have not been validated by independent pratitioners. In addition no level I or II studies have been published[10]. Poor patient satisfaction, high rates of revision due to loosening, and high wound complications rates were all very problematic when total ankle arthroplasty (TAA) surgeries were first introduced in the 1970’s.[11] In 1990, noncemented prostheses were shown to allow for bony ingrowth and less bone removal as compared to cemented.[11] Beyond the transition to cementless, further advances in technology over the years has led to new surgical arthroplasty techniques, primarily moving from a two-component design to a 3-component model. An observational study analyzed advantages of arthroplasty over arthrodesis stating individuals with monoarticular or polyarticular disease who undergo arthroplasty have less gait abnormalities and fewer adverse effects to other joints in the lower extremity.[12] A systematic review provided that in 852 individuals undergoing TAA's, there was a 78% implant survival 5 years post-op and 77% at 10 years post-op and overall only had a 7% revision rate. This provides evidence that the procedure yields satisfactory results and should be considered for potential candidates that are appropriate for surgical corrections.[13] The Arthroplasty Indication for Procedure There is no well-defined indication for a Total Ankle Arthroplasty. Surgery is considered only when conservative treatment has been attempted with no improvement. The operation is mainly being executed in patients who suffer from different types of arthrides. This cause advanced arthritic changes of disabling pain and loss of ankle motion. The ankle is most frequently affected by post-traumatic arthritis.[14] Total ankle joint replacement is also indicated following unsuccessful ankle arthrodesis [15] the ‘ideal’ patient for ankle joint replacement is an elderly person with the low physical demands who has good bone stock, normal vascular status, no immune-suppression, and excellent hind foot-ankle alignment.[16] Generally here are common indications for arthroplasty: Primary or post-traumatic osteoarthritis Severe rheumatoid arthritis Rejected arthrodesis Indications: According to Saltzman, there are no exact indications for receiving a total ankle arthroplasty.[17] The “ideal” patient who would typically undergo this intervention is one who is elderly with a healthy immunity, normal vascular status, good bone density, and a proper hindfoot-ankle alignment who has not had success with conservative treatment measures. Individuals with debilitating ankle arthritis, unresponsive to nonoperative approaches, or have failures with the outcome of their ankle arthroplasty are typically treated with an arthrodesis procedure to fuse the joint. Contraindications: Arthroplasty is contraindicated for those with neuroarthropathic degenerative joint disease, infection, avascular necrosis of the talus, osteochondritis dessicans, malalignment of the hindfoot-ankle, severe benign joint hypermobility syndromes or soft tissue problems, or decreased sensation or motion in the lower extremities.[11] In individuals with rheumatoid arthritis (RA), inflammatory processes may occur before signs of swelling, tissue reaction, and joint destruction are seen. In the first and second year of this disease process, structural damage (ie. joint erosion) can be seen with X-ray imaging.[18] Diabetic patients may develop gouty arthritis in their ankle joint. This is caused by uric acid changing into urate crystals, which is deposited into the joint.[18] Thus, RA and diabetic individuals may or may not be candidates for ankle arthroplasty depending on the severity of joint degeneration found with radiographic imaging. Common contraindications are: Severe talus subluxation, severe valgus or varus deformity Substantial osteoporosis Neurological disorders or recurrent infection Pre-operative Procedure and Definitive Diagnosis Weight bearing A-P and lateral mortise views of bilateral ankles is required to make effective preparation and anticipation of that will be required in the surgery. The rearfoot alignment (Cobey/Saltzman) view is essential to evaluate the ankle joint and identify any calcaneal-totibial deformities. This is performed by getting the patient to stand, elevated with a cassette positioned at 15 degres anteriorly inclined with the x-ray bemed perpendicular to the film. This position is altered if deformities are present, after this has been taken anterior distal tibial angle (ADTA) is measured. The ADTA is formed by the mechanical axis of the tibia and the joint orientation line of the ankle in the sagittal plane and measures 80° ± 3° in the normal lower extremity. In the coronal plane, the lateral distal tibial angle (LDTA), the tibial-talar angle and the calcaneal tibial alignment should be measured. The LDTA is formed by the distal tibial articular surface and the anatomical axis of the tibia and measures 89° ± 3°.29, if this is decreased this represents a varus deformity. The tibial-talar angle (Figure 3C) is defined by the tibial and talar articular surfaces in the ankle joint. When the tibialtalar angle is >10° the joint is defined as incongruent (unstable)[19]. "If an abnormal ADTA or LDTA is present (sagittal or coronal deformity), the center of rotation of angulation (CORA) is measured. The CORA is the intersection of the mid-diaphyseal line and the line starting from the middle of the joint and perpendicular to the abnormal ADTA or LDTA (Figure 4). The CORA can be located at the joint line level (usually due to anatomical joint line malalignment or to ankle degeneration) or proximally (usually due to tibial deformities/fractures)"[19]. So as you can see there are many consideration to be taken, and multiple angles to be analysed and this is important and any instability and malalignment of the new prosthesis can be excessively worn or may even fail[19]. Medical Management First generation: Early ankle prosthesis attempts involved cementing a stemmed metal ball into the tibia and a polyethylene cup cemented into the talus. Throughout the 1970’s, prosthesis evolved into using a vitallium component cemented into the talus. All designs used methylmethacrylate cement, which became the defining element of first generation prosthesis.[11] Types: Constrained - Increased stability due to only allowing dorsiflexion and plantarflexion. Loosening of the prosthesis was common from increased torque at the joint.[11] Nonconstrained - Allows full ROM, resulting in decreased stability that commonly caused impingement against the medial and/or lateral malleoli. Semiconstrained - A combination of contrained and nonconstrained models, allowing greater ROM and medial-lateral stability. The Imperial College, London Hospital prosthesis uses a concave polyethylene in the tibia and a stainless steel component on the talus.[11] Unfortunately, by the early 1980’s, first generation ankle arthroplasties were not recommended by the majority of orthaepedic surgeons. Numerous studies showed loosening of the cement fixation, wound issues, and low patient satisfaction [17][11]. As a result of the poor outcomes and high complication rate, surgeons began to recommended ankle arthrodesis. Second generation: Second generation arthroplasties are cementless, using bony ingrowth to stabilize the implant. Compared to cement, bony ingrowth prosthesis have less bone resection, damage to soft tissue and complications of the cement such as cement displacement[17]. Surgical Factors: Fixation: Ingrowth implants tend to have either a beaded surface along the bony interface, hydroxyapatite layer or a combination of both. Current surgical designs tend to use the combination fixation technique.[11][17] Between types of prosthesis the number of articulating surfaces and components both need to be considered.[17][11][20]. Components: Articulating surfaces: Current designs vary on the articulations that need to be resurfaced. Resurfacing may occur at the superior tibiotalar joint, superior and medial articulations, or medial, lateral, and superior joints.[11] Determining which patients would benefit the most from each type of surgery is ongoing.[17] Design components: 2 component implants include a tibial and talar articulating component. Implants may also incorporate syndesmosis fusion to resurface the medial and lateral recesses of ankle and converting the ankle from a 3-bone joint to a 2-bone joint. Known designs: Agility, Salto Talaris, Eclipse, INBONE Advantages: decreased shear and torsion on prosthesis[21], syndesmosis decreases shear force and increase the bony support for the tibial component[17] Disadvantages: increased bony resection, likelihood of soft tissue compromise, accelerated polyethylene wear, and possibility of syndesmosis fusion failure.[17] 2 Component Ankle Replacement Examples Salto Talaris Agility 3 component implants include a “mobile bearing” of polyethylene between the tibial plate and talar component. Known designs: Buechel-Pappas, Scandinavian Total Ankle Replacement (STAR), Mobility, HINTEGRA Advantages: low polyethylene wear rates, allow multiplanar motion[11], increased congruency, minimal bony resection[17][21] Disadvantages: mobile bearing segment may dislocate, more involved surgery, abnormal ligamentous stress due to malalignment of axis of rotation[17][11] 3 Component Ankle Replacement Examples STAR Buechel Pappas Both component designs permit semiconstrained motion, specifically allowing some inversion and eversion during sagittal plane ankle movement. The four 2 component designs have been approved by the U.S. Food and Drug Administration (FDA). The STAR was recommended for approval by the FDA in 2008.[22][21] There is insufficient evidence determining the life expectancy of current prosthesis designs.[21] Surgical Procedure To perfrom the procedure the patient is positioned supine with the hip slightly elevated and a tourniquet on the proximal thigh to restrict blood flow during the procedure. Next a 10 cm incision is made over the centre of the joint line to expose the relevent anatomical structures. Once the structures have been exposed the crucial nerves and tendons are identified as to protect and ensure their integrity to minimise operative complications, these include; peroneal nerves, tibialis anterior and extensor hallucis longus. This is also to achieve correct talocrural alignment and soft tissue balance to ensure the prosthesis can achieve plantar grade in standing. It is also important to debride and correct any osteophytes or any other structures that can contribute to malalignment. Depending on the natural angle of the talocrural joint (varus or valgus) more bone medially or laterally may have ot be removed, this also may occur if the joint is deep or shallow as it may need to be reduced or elevated[19]. Once the joints have been corrected and bones properly aligned the new components are trialed making sure rull ROM and stability is achieved. If dorsiflexion is limited and not due to malalignment then achilles tendon lengthening is required, the same goes for if there is instability in inversion or eversion the ligaments are reconstructed. Persistent malalignment can occure and may need separate procedures to correct such as subtalar fusion depending on severity and correctability[19]. Alternate Option: Ankle Arthrodesis Ankle arthrodesis or fusion was the recommended surgical option after the failure of the first generation ankle arthroplasty. The procedure includes resecting the articular surfaces of the joint, realignment the talus and tibia and fusing the bones together. As a result, the ankle joint doesn’t allow any motion. The goal of ankle arthrodesis is pain relief.[23][20] Unfortunately, the lack of ankle motion can cause elevated stress on the knee and hindfoot and in addition, increases motion at the hindfoot that may become arthritic.[11] Other complications of fusion include accelerated degeneration of adjacent joint and limitations in activity.[21] [24] Outcome Measures Foot and Ankle Disability Index Foot Function Index (FFI) Foot and Ankle Ability Measure (FAAM) Physical Therapy Management As it will be explained in the pre-operation and post-operation phase the multi-disciplinary team involved with the patient have a big role in making the arrangements before and after the surgery, this may involve physiotherapists, occupational therapists, discharge nurses, staff nurses, healthcare assistants as well as doctors. Both pre and post operative phases are integral to the progress of the patient and the pre-op should not be overlooked as important as it can be easy to focus on post-op. Pre-Operative Phase Before the surgery one of the main job for the team is to educate the patient about what will happen before, during and after the surgery as this will give the patient the opportunity to prepare, mentally rehearse, ensure smooth transition through short-term to long-term goals but also help control and reduce post-operative pain[25] (level of evidence 3B) ROM, muscle strength, gait and deviations will all be recorded as to compared before and after arthroplasty and ensure the patient is as optimal strength prior to operation if possible. For safety and ease of transition is can be important that the patient learns how to walk with crutches so they can perform ADL’s as soon as possible post arthroplasty but also understand that they will be non-weight bearing after the arthroplasty[26].(Level of evidence 4) As will all procedures under general anesthetic there are common pulmonary postoperative complications (PPC's) which need to be controlled and risk reduced and this can be explained at this stage as well. Post-Operative Phase It is important to ensure the risk of PPC's are reduced and respiratory physiotherapy may be used at this early stage, cough, deep breathing exercises and early mobility are essential here to reduce atelectasis and reinstate the muscoscilliary elevator as soon as possible. Atelecatsis occurs in 90% of anesthetized patients which leads to a 16-20% reduction in functional residual capacity which is why the alveoli tend collapse resulting in increased work of breathing, hypoxia, reduced compliance, V/Q mismatch and risk of pneumonia[27][28].(Level of evidence 5)T(Level of evidence 5)here is a 9% chance of developing pneumonia and this is where physiotherapy intervention is crucial at reducing the rate of all of these complications[29].(Level of evidence 5) IT IS IMPORTANT TO KNOW YOUR OWN HOSPITALS/SURGEONS GUIDELINES FOLLOWING ARTHROPLASTY OR ANY OPERATION AND THE FOLLOWING SHOULD ONLY BE USED TO EDUCATE AND CONSIDER SOME BASIC/COMMON PROTOCOLS THIS SHOULD NOT BE USED IN REPLACEMENT OF THE SURGEONS PROTOCOL THIS IS A PROTOCOL BY THE ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST[30], utilising the best available evidence[31][32][33][34][35][36] As can be expected after any type of surgery, pain and inflammation must be controlled. This is the case especially after ankle replacement because pain and inflammation can last up to 12 months after surgery.[37] Surrounding muscles can be damaged during surgery and can result in decreased range of motion and strength.[38][39][40] Damage to joint proprioceptors during excision of the capsule may cause deficits in both static and dynamic balance.[41][42] These components can lead to gait disability and decreased efficiency of locomotion.[43] Correction of gait posture and ambulation deficiencies will be a target of therapy once the patient is ambulating independently. Physical Therapy Goals: Decrease pain Decrease inflammation Increase strength Increase range of motion Improve dynamic and static balance Improve proprioception Proper independent ambulation Assessment Mechanism of injury or etiology of illness Date of surgery and type of implant Use of assistive device with weight bearing status Use of controlled ankle motion (CAM) walker/walking boot Functional deficits/assistance with ADLs/adaptive equipment Pain/ Symptom history: Location, duration, type, intensity (VAS), aggravating and relieving factors, 24 hour symptom behavior Relevant Current/Past Medical history: Other lower extremity arthritis or injuries,upper extremity issues that may limit ability to ambulate with an AD and comorbid diagnoses Medications for current/previous diagnoses Diagnostic tests Sleep disturbance Barriers to learning Social/occupational history Patient’s goals Vocation/avocation and associated repetitive behaviors Living environment Relevant Tests & Measures: Observation/inspection/palpation: Skin and incision assessment, edema, muscle atrophy Circulation: Dorsal pedal pulse Sensory and proprioception testing Range of motion and Muscle length: Average postoperative arc of motion (dorsifexion and plantarfexion) is 23°[44][45] Muscle strength Posture: Increased pronation/supination in standing, ability to maintain wait bearing status Assess assistive and adaptive devices for need and proper fit Balance: Static and dynamic standing balance, unilateral balance of the unaffected extremity (especially if patient is still non-weight bearing).[44] Patient may demonstrate dynamic postural imbalance, less reliance on ankle strategy and deficit of motor control ability[41] Functional mobility American Orthopaedic Foot and Ankle Society ankle-hindfoot score[46], Outcome measures Self-selected normal walking speed[47] Assess safety in mobility Gait Assessment[44] Initial Rehab 0-4 Weeks Restrictions: Non-weight bearing 2/52 with a back slab Below knee POP at 2/52 and begin full weight bearing in this POP POP removed at 4/52 and aircast boot is considered Elevation If sedentary employment, return to work at 4/52 as long as elevated and protected Goals: Safe and independent mobility with walking aid Independent with exercise programme Know monitoring and protection Treatment: POP Pain-relief POLICE Basic circulatory exercises Mobility Progress when: Out of POP, fully weight bearing, no complications and then refer to physiotherapy out patients Recovery Rehab 4 weeks - 3 months Restrictions: No strengthening against resistance until 3 months if any tendon transfers No stretching tendons if transferred Goals: Independent from aircast boot Achieve full ROM Treatment: Pain relief, swelling management Advice, education, postural advice, monitoring complications, pacing Gait re-education Exercises --> PROM,AAROM, AROM, light strengthening, core stability, balance/proprioception, stretching Hydrotherapy Orthotics Manual therapy --> SSTM's, mobilisations Progress when: Full ROM, independently mobile, neutral foot position in standing Intermediate Rehab 12 weeks - 6 months Restrictions: None Goals: Independent with no aids Normal footwear Grade 5 strength Grade 4 strength in tendons transferred Treatment: Pain relief, swelling management Advice, education, postural advice, monitoring complications, pacing Gait re-education Exercises --> PROM,AAROM, AROM, light strengthening, core stability, balance/proprioception, stretching Hydrotherapy Orthotics Manual therapy --> SSTM's, mobilisations Progress when: Normal footwear, independent with no aids, pain controlled, strength 5/5 (4/5 if tendon transferred) Final Rehab 6 months - 1 year Goals: Return to gentle no-impact/low impact sports Grade 5 strength in transferred tendons Treatment: Maximise function End stage exercises, balance and proprioception and sport specific Manual therapy Muscles to Consider Here is a unfinished list of some of the major muscles of the lower leg and foot, consider these in your rehabilitation and mechanism of pathology. Some may have had tendons moved or stretched and now need to be specifically rehabilitated as the proprioceptive function may now have changed. Posterior Compartment - Superficial Gastrocnemius Plantaris Soleus Posterior Compartment - Deep Popliteus Flexor Hallucis Longus Flexor Digitorum Longus Tibialis Posterior Lateral Compartment Peroneus Longus Peroneus Brevis Anterior Compartment Tibialis Anterior Extensor Hallucis Longus Extensor Digitorum Longus Peroneus Tertius Sample Exercises Balance c perturbation Ball toss Standing reach Standing reach Seated rocker board DF theraband Ankle eversion DF stretch Ankle PF Additional Information After the surgery it is important that the patient keeps moving and performing his daily activities. However there is still discussion between physicians about when the patient should start again with exercising. There are some that allow exercise immediately after surgery. But some say it is considered best to wait until there is a satisfactory bony in growth as shown radio graphically. However it’s the job of the physician to try to improve: the patient’s ROM of the ankle, maintain the ROM in the hip and knee, increase the muscle strength with exercise for the Gluteus Maximus, Quadriceps femoris muscles and the muscles that are responsible for dorsal flexion and the plantar flexion of the ankle[48]. Postoperative mobilization begins early, with rapid progression to resumption of normal activities.[49] The goal is to obtain 10° of dorsal flexion and 30° of plantar flexion. For patients who have almost no motion in their ankle is any motion an improvement.[50] In early postoperative period it is important that the incision heals and the implant becomes solidly fixed to the bony bed to do this they will use a below knee non-weight bearing immobilization. This is maintained until there is satisfactory bony in growth. [51]. Another goal is to increase the ROM of the ankle and maintain the hip and the knee ROM. After a few months the patient needs to make an appointment with the doctor. Here they will take X-ray scans to see if there are no complications like: joint debridement for osseous impingement; the next most common procedures were extra-articular procedures for axial misalignments and component replacements.[52] Prognosis & Outcome Outcome of ankle arthroplasty includes pain, function implant survival and complications. There are numerous studies looking at survival rate of implants and rates are reported around 67-94% at 5 years[53][54][55] and 75% at ten years[53] which is reasonably reliable. A systematic review of intermediate and long term outcomes of arthrolplasty and arthrodesis performed by Haddal et al[56] had interesting results. It reviewed 49 primary studies of 1262 patients and utilised the AOFAS score (Americal Orthopaedic Foot and Ankle Society). This score is out of 100 (0=worst outcome, 100=best outcome) broken into 8 sections of pain, function walking distance, walking surface, gait abnormality, sagittal mobility, hindfoot mobility, ankle hindfoot mobility and alignment. The score has mixed reviews and the objective aspect of the score is hard to make reliable between therapists[57]. The mean AOFAS score was 78.2 points for the patients treated with total ankle arthroplasty and 75.6 points for those treated with arthrodesis. Meta-analytic mean results showed 38% of the patients treated with total ankle arthroplasty had an excellent result, 30.5% had a good result, 5.5% had a fair result, and 24% had a poor result. In the arthrodesis group, the corresponding values were 31%, 37%, 13%, and 13%. The five-year implant survival rate was 78% and the ten-year survival rate was 77%. The revision rate following total ankle arthroplasty was 7% with the primary reason for the revisions being loosening and/or subsidence (28%). The revision rate following ankle arthrodesis was 9% , with the main reason for the revisions being nonunion (65%). One percent of the patients who had undergone total ankle arthroplasty required a below-the-knee amputation compared with 5% in the ankle arthrodesis group. Their conclusion was that on the basis of these findings, "the intermediate outcome of total ankle arthroplasty appears to be similar to that of ankle arthrodesis; however, data were sparse. Comparative studies are needed to strengthen this conclusion"[56]. Resources [58] [59] [60] [61]Physical Activity Pre and Post Surgery - PhysiopediaBenefits of Exercise Pre and Post Surgery The effect of exercise on outcomes after surgery has been extensively studied in a number of populations. The most common populations studied are Those post- hip replacement Those post- knee replacement Those post- cardiac surgery Those post- abdominal surgery Other surgical groups such as colorectal, thoracic, post- cancer resection, vascular and urological Whilst the evidence is good in general terms, unfortunately, as yet there is no clear consensus on the specifics of exercise prescription pre-surgery[1]. Studies can be divided into those that look at the effect of interventions pre-operatively on post- surgical outcomes and those that look at the effect of different exercise interventions post- surgery. What Are the General Benefits of Preoperative Exercise? The evidence that if cardiorespiratory fitness (CRF) is measured preoperatively, it is predictive of complications in the postoperative period is compelling, with several studies demonstrating this across different types of surgeries[2][3][4][5][6][7] The measure of CRF also offers significant advantage when compared to age alone in predicting mortality after major surgery[5]. CRF is a significant independent predictor of length of stay in hospital with patients older than 75 A low CRF is associated with an average of 11 days longer in hospital and 2 days longer in critical care Pre-operative exercise reduces the length of stay both in Intensive Care facilities and in hospital[8][1]. It also exerts beneficial effects on physical fitness and postoperative outcomes measures across various surgical fields.including cardiac surgery, orthopedic surgery, abdominal surgery, thoracic surgery, vascular surgery and urologic surgery[9]. In their scoping study, Pouwels et al (2016) conclude that more research is needed to focus on heterogeneous outcome measures, patient populations and guidelines for exercise regimes[9]. What Are the Benefits of Preoperative Exercise in Specific Populations? Hip Replacement In patients undergoing this surgery, significant improvements (small to moderate effect sizes) have been observed in pain, function, and length of stay with exercise interventions preoperatively. [10] Knee Replacement A 2014 systematic review (Chesham and Shanmugham) concluded that there is minimal evidence so far supporting education and exercise interventions pre-operatively, compared with no physiotherapy or usual care. Interventions reviewed in the 10 RCTs were preoperative exercise; combined exercise and education; combined exercise and acupuncture; neuromuscular electrical stimulation; and acupuncture versus exercise. Outcomes assessed were knee strength, ambulation, and pain. Good quality research into this is ongoing[11]. However Moyer et al (2017) in their systematic review and meta analysis found small to moderate effect sizes for pre-rehabilitation in this population. Significant improvements were made in function, quadriceps strength and length of stay.[10] Cardiac Surgery A Cochrane review in 2012 found that evidence from small trials suggests that preoperative physical therapy, with an exercise component, for elective cardiac surgery patients reduces postoperative pulmonary complications and length of hospital stay. They concluded that there is a lack of evidence to effect changes to postoperative pneumothorax, or prolonged mechanical ventilation[12]. It has been known for some years that inspiratory muscle training provided pre-operatively reduces the risk of anaesthetic complications as well as reducing post-operative complications[13] as well as length of postoperative hospital stay and pulmonary function[14]. Pre-operative exercise reduces the length of stay both in Intensive Care facilities and in hospital[8][1]. Abdominal Surgery O'Doherty et al (2013) in their systematic review conclude that pre-operative exercise reduces the length of stay both in Intensive Care facilities and in hospital[8][1]. A meta-analysis and systematic review done in 2016 (Moran et al) concluded that more research was needed, but 'prehabilitation' consisting of inspiratory muscle training, aerobic exercise, and/or resistance training can decrease postoperative complications after intra-abdominal operations.[15] Other Mixed Populations A systematic review in 2010 found that preoperative exercise therapy is effective for reducing both postoperative complication rates and length of hospital stay after cardiac or abdominal surgery[16]. A Cochrane review in 2015 concluded that preoperative inspiratory muscle training reduced the incidence of postoperative pulmonary complications (such as actelectasis and pneumonia) and length of hospital stay compared with usual care in adults undergoing cardiac and major abdominal surgery[17]. Colorectal Surgery A study on patients undergoing colorectal surgery found benefits from exercise programmes pre-operatively: improved physical function, peak exercise capacity, mental health and self-perceived health[18] Cancer-resection surgery A Cochrane review in 2017 found low quality evidence that preoperative exercise training may reduce some risks in those having lung resection surgery for early stage non-small cell lung cancer (NSCLC).[19]. These were- developing postoperative pulmonary complications, duration of intercostal catheter use, a reduced postoperative length of stay and improved exercise capacity and FVC post-operatively. [19] What Are the Benefits of Post-Operative Exercise? There is clear evidence for the following surgeries: Spinal surgery - improved spinal mobility[20] Total Hip and Knee Replacement surgery - earlier discharge[21] Colorectal surgery - increased cardiovascular fitness[22] Breast surgery - fewer side-effects[23] In many surgeries: reduced risk of blood clots[24] Cardiac surgery - inspiratory muscle training on length of postoperative hospital stay and pulmonary function [14] Contraindications to Exercise Pre/Post Surgery In addition to the absolute contraindications (see the Exercise Physiology page), specific precautions will apply depending on the surgery. The treating team ( Doctors, Nurses, Physiotherapists) will give the patient specific advice on this. Resources The Motivate2Move website, created by Wales Deanery, has a comprehensive section on surgery and exercise.ReferencesLevine BR, Klein GR, Cesare PE. 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Comparison of primary total hip replacements performed with a direct anterior approach versus the standard lateral approach: perioperative findings. J Orthopaed Traumatol 2011;12:123-129.Verywell Health. Orthopedics - hip and knee - replacement http://implants.http://orthopedics.about.com/od/hipkneereplacement/a/implants.htm (accessed 23/07/2018).Bader R, Steinhauser E, Zimmermann S, Mittelmeier W, Scholz R, Busch R. Differences between the wear couples metal-on-polyethylene and ceramic-on-ceramic in the stability against dislocation of total hip replacement. Journal of materials science: materials in medicine 2004;15(6):711-8.Garcia-Rey E, Cruz-Pardos A, Garcia-Cimbrelo E. Alumina-on-alumina total hip arthroplasty in young patients: diagnosis is more important than age. Clinical Orthopaedics and Related Research 2009;467(9):2281-9.Mahendra G, Pandit H, Kliskey K, Murray D, Gill HS, Athanasou N. 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