Oren Tirosh

Routine postoperative radiographs are common after total knee arthroplasty (TKA), yet their value for assessing early joint balance is unclear. Immediate supine, non-weight-bearing anteroposterior radiographs may show coronal gap asymmetry, but its long-term significance remains uncertain. This study evaluated whether medial–lateral joint space differences on day-one radiographs correlate with midterm patient-reported outcomes. A retrospective cohort of 637 mechanically aligned primary TKAs (556 patients, 2012–2017) was analysed. Medial and lateral gaps were digitally measured on immediate postoperative supine AP and lateral radiographs. Gap asymmetry was expressed as an absolute difference and as a medial-to-lateral ratio. Patient-reported outcome measures (PROMs)—Oxford Knee Score (OKS), pain VAS, and EQ-5D VAS—were assessed at ≥ 3 years. Multivariable linear and logistic regression adjusted for age, sex, and BMI examined associations between radiographic imbalance and outcomes. Median follow-up was 5.4 years. The median lateral–medial gap difference improved from 4.9 mm preoperatively to 0 mm postoperatively. In women < 70 years, each 1-mm medial opening was associated with a 1-point lower OKS and 2.4-point lower EQ-5D VAS. A 100% increase in the medial–lateral ratio predicted an 8.8-point lower OKS in women < 60 years and a 4-point lower OKS in women 60–70 years. Medial opening ≥ 1.5 mm predicted poorer OKS and EQ-5D scores, whereas mild lateral opening showed outcomes comparable to symmetric knees. No significant associations were found in men. Medial joint space widening ≥ 1.5 mm or ≥ 100% ratio increase on day-one radiographs predicts poorer midterm outcomes in women < 70 years, suggesting that early coronal imbalance has lasting clinical relevance in this group.

Alexander David Puyol, PT, DPT, Charlotte Ganderton, PT, PhD, Matthew King, PT, PhD, Oren Tirosh, PhD. Hip Pelvis 2026;38:117-26. https://doi.org/10.5371/hp.2026.38.2.117

Background: Rising demand for total hip arthroplasty (THA) and total knee arthroplasty (TKA) places significant pressure on healthcare systems. Routine in-person follow-up is resource-intensive and may limit access for new or higher priority patients. The Connected Care protocol integrates telehealth with patient-reported outcome measures (PROMs) to support a more efficient and patient-centred model of post-operative care. Methods: Over 2 years in a public health institution, all THA and TKA patients completed routine pre-operative and post-operative PROMs. Patients scoring ≤27 on the Oxford hip score or Oxford knee score, and/or requested further clinical review, were triaged to telehealth consultation. Following telehealth assessment, patients were either booked for face-to-face review, discharged from routine follow-up, or managed with ongoing remote monitoring. Results: 1272 patients returned PROMs. Of these, 451 patients (35.5%) scored ≤27 and/or requested further review. Following telehealth consultation, 47 (10.4%) were discharged from face-to-face care, while 71 (15.7%) previously discharged had appointments reinstated for timely in-person review. Among 821 patients (64.5%) who scored >27 and did not request further review, 169 (20.6%) had pre-existing face-to-face appointments cancelled. Overall, the Connected Care protocol generated 216 additional orthopaedic outpatient appointment slots over the 24-month period. Discussion: PROM-guided telehealth triage enabled risk-stratified, patient-centred follow-up post-THA/TKA, improving outpatient capacity within a publicly funded orthopaedic service. It reduced low-value outpatient encounters while preserving access to face-to-face care when clinically indicated. Future development should incorporate post-operative radiographic review, extend the model to other orthopaedic pathways, and enhance cultural and linguistic accessibility to support equitable digital post-operative care.

Wheelchair users face significant mobility limitations related to both medical issues (e.g., musculoskeletal strain, pressure ulcers) and urban accessibility challenges. This pilot study introduces a sensor system integrating an inertial measurement unit (IMU), GPS (Global Positioning System), and a pressure-measuring seat to monitor distance travelled, speed, and posture in relation to real-world conditions. Seven participants navigated an approximately 800-metre outdoor course, divided into 13 sections, while real-time data were recorded. The results showed an average speed of 1.24 ± 0.41 m/s with peak speeds of up to 2.67 m/s. The centre of pressure on the seat fluctuated by an average of 25 mm in the x and y directions (left-right: COPx, back-forward: COPy). The data for average speed, COPx, and COPy showed significant differences between most of the 13 sections, with large, very large, and huge effect sizes. Comparing the speed, COPx, and COPy data with respect to distance travelled, and correlating them between the seven participants by applying the rank-sum method to the mean R² and calculating Kendall’s W, revealed that speed, COPx, and COPy were influenced by course conditions (R² medians between 0.013 and 0.499; W = 0.7857, strong agreement; χ²p = 0.0281). Small R² values indicate more individualised participant behaviour, while large R² values highlight the stronger influence of course conditions on the parameters. This non-invasive and cost-effective system provides objective motion data that can be used for future research in wheelchair design and rehabilitation strategies. Despite its advantages, this study was limited to able-bodied participants, so further clinical trials with individuals with mobility impairments are needed.

Background: The Balance Error Scoring System (BESS) is the most practiced static postural balance assessment tool, which relies on visual observation, and has been adopted as the gold standard in the clinic and field. However, the BESS can lead to missed and inaccurate diagnoses—because of its low inter-rater reliability and limited sensitivity—by missing subtle balance deficits, particularly in the athletic population. Smartphone technology using motion sensors may act as an alternative option for providing quantitative feedback to healthcare clinicians when performing balance assessments. The primary aim of this study was to explore the discriminative validity of an alternative novel smartphone-based cloud system to measure balance remotely in soccer athletes with and without hip pain. Methods: This is an exploratory cross-sectional study. A total of 64 Australian soccer athletes (128 hips, 28% females) between 18 and 40 years completed single and tandem stance balance tests that were scored using the modified BESS test and quantified using the smartphone device attached to their lower back. An Exploratory Factor Analysis (EFA) and a Clustered Receiver Operating Characteristic (ROC) using an Area Under the Curve (AUC) were used to explore the discriminative validity between the smartphone sensor system and the modified BESS test. A Linear Mixed-Effects Analysis of Covariance (ANCOVA) was used to determine any statistical differences in static balance measures between individuals with and without hip-related pain. Results: EFA revealed that the first factor primarily captured variance related to smartphone measurements, while the second factor was associated with modified BESS test scores. The ROC and the AUC showed that the smartphone sway measurements in the anterior–posterior and mediolateral directions during single-leg stance had an acceptable to excellent level of accuracy in distinguishing between individuals with and without hip-related pain (AUC = 0.72–0.80). Linear Mixed-Effects ANCOVA analysis found that individuals with hip-related pain had significantly less single-leg balance variability and magnitude in the anteroposterior and mediolateral directions compared to individuals without hip-related pain (p < 0.05). Conclusion: Due to the ability of smartphone technology to discriminate between individuals with and without hip-related pain during single-leg static balance tasks, it is recommended to use the technology in addition to the modified BESS test to optimise a clinician-led assessment and to further guide clinical balance decision-making. While the study supports smartphone technology as a method to assess static balance, its use in measuring balance during dynamic movements needs further research.

Chronic ankle instability (CAI) poses challenges in sports. Textured insoles are a promising intervention for optimizing ankle muscle activity and enhancing ankle proprioceptive ability in individuals with CAI. This study investigated the effects of different types of insoles on ankle muscle activity and ankle inversion proprioception during drop-landing tasks. Thirty-two soccer players (16 CAI, 16 non-CAI) participated in the study. Electromyographic (EMG) activity of the tibialis anterior (TA), medial gastrocnemius (MG), and peroneus longus (PL) muscles was recorded during drop-landing tasks using the ankle inversion discrimination apparatus for landing (AIDAL) with textured insoles (TI) and standard flat insoles (SI). Ankle inversion proprioception was assessed using the AIDAL. Muscle activity was analyzed for pre- and initial contact phases. CAI players showed significantly reduced TA activity compared to non-CAI players during both pre-initial (2.62 ± 1.86 vs. 5.53 ± 5.15; p = 0.04) and initial contact phases (18.7 ± 13.6 vs. 29.9 ± 20.6; p = 0.01). CAI players also exhibited greater MG activity during pre-initial (16 ± 6.15 vs. 12.5 ± 6.38; p = 0.03) and initial contact phases (60.8 ± 32.5 vs. 41.5 ± 14.8; p = 0.004), and higher PL activity during the pre-initial contact phase (7.39 ± 4.75 vs. 4.28 ± 2.83; p = 0.003). No significant CAI/insole main effects or interactions (p > 0.05) were observed in AIDAL proprioceptive scores. Overall, CAI players showed significant alterations in ankle muscle activity during drop-landing tasks. Increased PL activity during the pre-initial contact phase may serve as a compensatory strategy to enhance ankle stability, while reduced TA and increased MG activation during pre-initial and initial contact phases may contribute to the high incidence of recurrent ankle sprains in CAI individuals. Additionally, the lack of immediate effects from insoles on muscle activity suggests that their influence on sensory input and foot positioning may require prolonged use to induce measurable neuromuscular adaptations.

Objective: To investigate whether lower limb proprioception and postural control strategies are impaired in people with non-specific low back pain. Data sources: A literature search was performed in the Cochrane Library, Web of Science, PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature, between January 2000 and June 2025. Review methods: Studies comparing lower limb proprioception and postural control strategies in adults with non-specific low back pain versus asymptomatic controls were included. Postural control was assessed through relative proprioception weighting, with higher values indicating greater reliance on ankle strategies and lower values indicating reliance on hip strategies. Quality appraisal utilised the Newcastle-Ottawa scale, while evidence certainty was evaluated using the grading of recommendations assessment, development and evaluation system. Results: Seventeen studies with 1187 participants were included, of which 14 had Newcastle-Ottawa Scale scores above five. The pooled analysis showed that the non-specific low back pain group had significantly decreased ankle proprioception compared to the control group (standardised mean difference = −0.710). People with non-specific low back pain relied more on ankle strategies for postural control on both stable (weighted mean difference = 0.086) and unstable surfaces (weighted mean difference = 0.195). However, the three pooled outcome measures showed very low level of evidence due to research design and heterogeneity. Conclusion: Very low level of evidence showed that people with non-specific low back pain had impaired lower limb proprioception and a higher reliance on an ankle strategy compared to asymptomatic controls, suggesting potential benefits of assessing and improving lower limb function in this population.