Neuromuscular performance and body mass as indices of bone loading in premenopausal and postmenopausal women.

The strong association between body mass and skeletal robusticity has been attributed to increasing skeletal loading with increasing mass. However, it is unclear whether body mass is merely a coarse substitute for bone loading rather than a true independent predictor of bone strength. As indices of neuromuscular performance, impulse and peak power were determined from vertical ground reaction force during a maximal counter movement jump test in 221 premenopausal and 82 postmenopausal women. Bone compressive (BSI(d) g(2)/cm(4)) and bending (SSImax(mid) mm(3)) strength indices were measured with peripheral quantitative computed tomography (pQCT) at the distal ((d)) and midshaft ((mid)) sites …

Reproducibility of imaging human knee cartilage by delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) at 1.5 Tesla

Summary Objective The purpose of this study was to investigate the day-to-day reproducibility of the delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) measurement at different knee joint surfaces in healthy subjects at 1.5 Tesla (T). Methods The dGEMRIC experiment was repeated for 10 asymptomatic volunteers three times with an average interval of 5 days between scans. The measurement was performed from a single sagittal slice through the center of the lateral femoral condyle and from the center of the patella in the axial plane. Cartilage was manually segmented into superficial, deep and full-thickness regions of interests (ROIs) at different topographical locations of the femur, tibia…

Regular physical exercise before entering military service may protect young adult men from fatigue fractures

Background Bone stress fractures are overuse injuries commonly encountered in sports and military medicine. Some fatigue fractures lead to morbidity and loss of active, physically-demanding training days. We evaluated the incidence, anatomical location, risk factors, and preventive measures for fatigue fractures in young Finnish male conscripts. Methods Five cohorts of 1000 men performing military service, classified according to birth year (1969, 1974, 1979, 1984, 1989), were analysed. Each conscript was followed for his full military service period (180 days for conscripts with rank and file duties, 270 days for those with special training, 362 days for officers and highly trained conscri…

Bone mineral density of the proximal femur after hip resurfacing arthroplasty: 1-year follow-up study

Abstract Background Hip resurfacing arthroplasty (HRA) is considered a bone-preserving procedure and may eliminate proximal femoral stress shielding and osteolysis. However, in addition to implant-related stress-shielding factors, various patient-related factors may also have an effect on bone mineral density (BMD) of the proximal femur in patients with HRA. Thus, we studied the effects of stem-neck angle, demographic variables, and physical functioning on the BMD of the proximal femur in a one-year follow-up. Methods Thirty three patients (9 females and 24 males) with a mean (SD) age of 55 (9) years were included in the study. BMD was measured two days and 3, 6, and 12 months postoperative…

Physical activity and ability to meet different work requirements among adult working men with or without current depressive symptoms

Abstract Purpose To examine the relationship between leisure-time physical activity (LTPA) and ability to meet different work requirements among adult working men with or without current depressive symptoms. Methods We measured LTPA with the long version of the International Physical Activity Questionnaire (IPAQ). The Work Ability Index (WAI) and Beck Depression Inventory (BDI) were used to assess the work ability and depression of 921 Finnish employed male volunteers. Participants were divided into three groups according to the WAI for their work requirements: mental (MENT), physical (PHYS), and an equal amount of mental and physical work (BTH). Results When adjusted for age, BMI and emplo…

Effects of a progressive aquatic resistance exercise program on the biochemical composition and morphology of cartilage in women with mild knee osteoarthritis: protocol for a randomised controlled trial

Background Symptoms associated with osteoarthritis of the knee result in decreased function, loss of working capacity and extensive social and medical costs. There is a need to investigate and develop effective interventions to minimise the impact of and even prevent the progression of osteoarthritis. Aquatic exercise has been shown to be effective at reducing the impact of osteoarthritis. The purpose of this article is to describe the rationale, design and intervention of a study investigating the effect of an aquatic resistance exercise intervention on cartilage in postmenopausal women with mild knee osteoarthritis. Methods A minimum of 80 volunteers who meet the inclusion criteria will b…

ASSOCIATION BETWEEN LEISURE TIME PHYSICAL ACTIVITY LEVEL AND ARTICULAR CARTILAGE IN POSTMENOPAUSAL WOMEN WITH MILD KNEE OSTEOARTHRITIS: A 12-MONTH FOLLOW-UP STUDY AFTER 4-MONTH INTERVENTION

Long-term clinical and radiographic outcomes and patient satisfaction after adult spinal deformity correction

Background and Aims: Adult spinal deformity surgery has increased with the aging population and modern surgical approaches, although it has high complication and reoperation rates. The permanence of radiographic correction, mechanical complications, predictive factors for poor patient-reported outcomes, and patient satisfaction were analyzed. Material and Methods: A total of 79 adult patients were retrospectively analyzed at baseline and 1–9 years after adult spinal deformity correction between 2007 and 2016. Patient-reported outcomes (Oswestry Disability Index, visual analog scale, and Scoliosis Research Society–30 scores), changes in radiographic alignment, indications for reoperation, pr…

Type of surgery is associated with pain and walking difficulties among older people with previous hip fracture

Aim The aim was to assess the level of lower body pain among people with previous femoral neck fracture, and whether the type of surgery was associated with pain and physical function a mean of 2 years after surgery. Methods The study included 115 community-dwelling older adults aged 60 years and older with previous femoral neck fracture, and 31 reference subjects without previous lower limb injuries. A total of 30 patients had internal fixation surgery, 70 had hemiarthroplasty and 15 had total hip replacement. All patients had surgery in the same hospital and received typical inpatient rehabilitation. From 1.6 months to 7.5 years after the fracture, the patients underwent examination inclu…

Relationships of leisure-time physical activity and work ability between different occupational physical demands in adult working men

Purpose: Leisure-time physical activity (LTPA) is known to be associated with positive health benefits, but the role of occupational physical demands remains inconsistent. The purpose of the current study was to assess the relationship between LTPA and work ability in different occupational physical activity (OPA) levels between young adult men. - Methods: We performed physical activity measurements in work and leisure time with the long version of International Physical Activity Questionnaire (IPAQ) and work ability with the Work Ability Index (WAI) in 921 Finnish employed male volunteer participants. The participants were divided into LTPA tertiles I ( 28 MET-h/week) and OPA tertiles I (0…

Quantification of Bone Density of the Proximal Femur After Hip Resurfacing Arthroplasty—Comparison of Different DXA Acquisition Modes

Total hip arthroplasty (THA) is a traditional operative procedure in the treatment of osteoarthritis. The hip resurfacing arthroplasty (HRA) provides an alternative to the THA for young active patients. HRA is a bone-preserving procedure eliminating the problem of proximal femoral stress shielding and osteolysis associated to THA. Unfortunately, there is no standardized methodology to monitor the quality of bone after HRA. In this study, areal bone mineral density (BMD) in the operated hip (10 regions of interests [ROIs] of 34 volunteered HRA patients) was measured using Lunar Prodigy dual-energy X-ray absorptiometry, and the agreement of a standard (dual femur) and an orthopedic (orthopedi…

Bone Density, Structure and Strength, and Their Determinants in Aging Sprint Athletes

This study was undertaken to examine bone properties in masters sprinters of different ages and younger reference subjects. In addition, the association of sport-specific ground reaction force, muscle, training, and hormone characteristics with the bone parameters was evaluated in the athletes.Bone densitometric, structural, and strength parameters were assessed by peripheral quantitative computed tomography at the distal and midtibia in 83 male sprinters (40-85 yr) and 19 physically active referents (31-45 yr). Between-group differences were analyzed by ANCOVA with body mass and height as covariates.Bone values were generally greater in athletes than referents, the greatest differences bei…

High intensity aquatic exercise or daily physical activity for maintaining fat mass and walking ability for postmenopausal women with knee osteoarthritis?

Physical Activity Is Related with Cartilage Quality in Women with Knee Osteoarthritis

Purpose To study the relationship between 12-month leisure-time physical activity (LTPA) level and changes in estimated biochemical composition of tibiofemoral cartilage in postmenopausal women with mild knee osteoarthritis (OA). Methods Originally, 87 volunteer postmenopausal women, age 60 to 68 yr, with mild knee OA (Kellgren Lawrence I/II and knee pain) participated in a randomized controlled, 4-month aquatic training trial (RCT), after which 76 completed the 12-month postintervention follow-up period. Self-reported LTPA was collected along the 12-month period using a diary from which MET task hours per month were calculated. Participants were divided into MET task hour tertiles: 1, lowe…

Influence of Different DXA Acquisition Modes on Monitoring the Changes in Bone Mineral Density After Hip Resurfacing Arthroplasty

Dual-energy X-ray absorptiometry (DXA) is a technique enabling the measurement of bone mineral density (BMD) around prostheses after hip resurfacing arthroplasty (HRA). In this study, we evaluated the consistency of different DXA acquisition modes with 33 patients who had undergone HRA. Patients were scanned with DXA immediately after surgery and at 3-, 6-, and 12-mo time points. All the patients were scanned with dual femur and orthopedic hip acquisition modes and analyzed using 10-region ROI model. With both acquisition modes, a statistically significant decrease (p0.05, Wilcoxon's test) in BMD at 3mo was revealed in 3 ROIs, located to upper and lateral upper femur. Both acquisition modes…

Effects of high intensity resistance aquatic training on body composition and walking speed in women with mild knee osteoarthritis : a 4-month RCT with 12-month follow-up

Objective: To investigate the effects of 4-months intensive aquatic resistance training on body composition and walking speed in post-menopausal women with mild knee osteoarthritis (OA), immediately after intervention and after 12-months follow-up. Additionally, influence of leisure time physical activity (LTPA) will be investigated. Design: This randomised clinical trial assigned eighty-seven volunteer postmenopausal women into two study arms. The intervention group (n = 43) participated in 48 supervised intensive aquatic resistance training sessions over 4-months while the control group (n = 44) maintained normal physical activity. Eighty four participants continued into the 12-months' fo…

Impaired geometric properties of tibia in older women with hip fracture history.

This study evaluated side-to-side differences in tibial mineral mass and geometry in women with previous hip fracture sustained on average 3.5 years earlier. Both tibial mineral mass and geometry were found to be reduced in the fractured leg. INTRODUCTION: The purpose of this study was to evaluate side-to-side differences in tibial mineral mass and geometry after hip fracture and to assess the determinants of such differences. METHODS: Thirty-eight 60- to 85-year-old women with a previous hip fracture and 22 same-aged control women without fractures participated in the study. Bone characteristics of the distal tibia and tibial shaft of both legs were assessed using pQCT in order to compare …

Construct validity and reliability of the Finnish version of the Knee Injury and Osteoarthritis Outcome Score

Background The Knee Injury and Osteoarthritis Outcome Score (KOOS) is a commonly used knee assessment and outcome tool in both clinical work and research. However, it has not been formally translated and validated in Finnish. The purpose of this study was to translate and culturally adapt the KOOS questionnaire into Finnish and to determine its validity and reliability among Finnish middle-aged patients with knee injuries. Methods KOOS was translated and culturally adapted from English into Finnish. Subsequently, 59 patients with knee injuries completed the Finnish version of KOOS, Western Ontario and McMaster Osteoarthritis Index (WOMAC), Short-Form 36 Health Survey (SF-36) and Numeric Pai…

Effects of resistance training on lower-extremity impairments in older people with hip fracture

Abstract Portegijs E, Kallinen M, Rantanen T, Heinonen A, Sihvonen S, Alen M, Kiviranta I, Sipila S. Effects of resistance training on lower-extremity impairments in older people with hip fracture. Objective To study the effects of resistance training on muscle strength parameters, mobility, and balance. Design Randomized controlled trial. Setting Research laboratory and senior gym. Participants Population-based sample of eligible 60- to 85-year-old community-dwelling men and women 0.5 to 7.0 years after hip fracture. Forty-six people had no contraindications and were willing to participate in the exercise trial. Intervention Twelve-week intensive progressive strength-power training (n=24),…

Effects of Exercise on Patellar Cartilage in Women with Mild Knee Osteoarthritis

AB Purpose: This study aims to investigate the effects of exercise on patellar cartilage using T2 relaxation time mapping of magnetic resonance imaging in postmenopausal women with mild patellofemoral joint osteoarthritis (OA). Methods: Eighty postmenopausal women (mean age, 58 (SD, 4.2) yr) with mild knee OA were randomized to either a supervised progressive impact exercise program three times a week for 12 months (n = 40) or a nonintervention control group (n = 40). Biochemical properties of cartilage were estimated using T2 relaxation time mapping, a parameter sensitive to collagen integrity, collagen orientation, and tissue hydration. Leg muscle strength and power, aerobic capacity, and…

Loading and gait symmetry during level and stair walking in asymptomatic subjects with knee osteoarthritis: importance of quadriceps femoris in reducing impact force during heel strike?

Repetitive impulsive forces during walking are claimed to result in joint osteoarthritis (OA). The aim of this study was to investigate impact loading and gait symmetry during level and stair walking in asymptomatic elderly subjects with knee OA. It was hypothesised that pre-activity of the quadriceps femoris muscle (QF) would be an important factor reducing impulsive loading when walking on level ground. Subjects [21 female, six men, 66.2 (7.6) years] were studied. The subjects had no knee pain or diminished functional capacity, but showed radiographically light or moderate bilateral knee OA changes. Ground reaction forces (GRFs), plantar pressure distribution, muscle activation pattern [v…

Relations between subdomains of physical activity, sedentary lifestyle, and quality of life in young adult men

Purpose To assess the relationship between physical activity (PA) in work, transport, domestic and leisure-time domains (with sitting time included) and health-related quality of life (HRQoL) among young adult men. Methods The long version of IPAQ and SF-36 Health Survey were used to assess PA and HRQoL, respectively, in 1425 voluntary 20 to 40 year old Finnish male participants. Participants were divided into tertiles (MET-h/week): Lowest tertile ( 100 MET-h/week). Results The IPAQ domain leisure-time PA predicted positively the Physical Component Summary (PCS) (β=0.11, 95% CI: 0.06 to 0.16) and Mental Component Summary (MCS) (β=0.11, 95% CI: 0.05 to 0.16) dimensions. Occupational PA predi…

Additional file 1: of Construct validity and reliability of the Finnish version of the Knee Injury and Osteoarthritis Outcome Score

The back-translation of the Finnish version of the KOOS questionnaire “KOOS KNEE QUESTIONNAIRE”. (PDF 87 kb)

Reoperations after first lumbar disc herniation surgery; a special interest on residives during a 5-year follow-up

Abstract Background The overall rate of operations after recurrent lumbar disc herniation has been shown to be 3–11%. However, little is known about the rate of residives. Thus the aim of this study was to explore the cumulative rates of re-operations and especially residive disc herniations at the same side and level as the primary disc herniation after first lumbar disc herniation surgery and the factors that influence the risk of re-operations over a five year follow-up study. Methods 166 virgin lumbar disc herniation patients (mean age 42 years, 57% males) were studied. Data on patients' initial disc operations and type and timing of re-operations during the follow-up were collected fro…

The effects of muscle strength and power training on mobility among older hip fracture patients

The incidence of hip fractures is growing in all Western societies. The mobility of hip fracture patients does not return to the pre-fracture level even 2 years after fracture. One reason for mobility limitation may be the persistent muscle weakness on the fractured leg. The purpose of this randomized controlled study was to examine whether 12-week muscle strength and power training twice a week has an effect on mobility in 60–85-year-old hip fracture patients. Forty-three persons were randomly assigned to an intervention (n=23) and a control (n=20) group. The intervention comprised 12-week supervised intensive progressive strength–power training twice per week. All the measurers were blind…

Effects of High-Impact Training on Bone and Articular Cartilage: 12-Month Randomized Controlled Quantitative MRI Study

Osteoarthritis and osteoporosis often coexist in postmenopausal women. The simultaneous effect of bone-favorable high-impact training on these diseases is not well understood and is a topic of controversy. We evaluated the effects of high-impact exercise on bone mineral content (BMC) and the estimated biochemical composition of knee cartilage in postmenopausal women with mild knee osteoarthritis. Eighty women aged 50 to 66 years with mild knee osteoarthritis were randomly assigned to undergo supervised progressive exercise three times a week for 12 months (n = 40) or to a nonintervention control group (n = 40). BMC of the femoral neck, trochanter, and lumbar spine was measured by dual-energ…

Muscle strength and range of movement deficits 1 year after hip resurfacing surgery using posterior approach.

The aim was to evaluate the effect of the posterior surgical approach on hip muscle strength and range of movement (ROM).Maximal isometric external and internal rotator strength of the hip muscles and bilateral leg extension strength were measured by dynamometers. Active (AROM) and passive (PROM) range of motion of the hip were measured by goniometers in 30 patients before and 3, 6 and 12 months after hip resurfacing. Postoperatively the patients were advised to return to their usual physical activities.Prior to the surgery internal rotation strength was on the same level on both sides, whereas external rotation strength of the operated hip was 26% (p0.001) lower compared with the unoperate…

Effects of intensive strength-power training on sense of coherence among 60-85-year-old people with hip fracture: A randomized controlled trial

Background and aims: Older people with disabilities are at increased risk of psychological health decline. There are no earlier studies on the effects of resistance training on sense of coherence (SOC) among older people with a history of hip fracture. The aim of this study is to test the effects of intensive 12-week strength-power training on SOC among older adults after hip fracture. Methods: A clinical sample of 60-85-year-old community-dwelling men and women was studied, 0.5. to 7.0 years after hip fracture. Forty-six had no contraindications for participation and were randomized into training (n=24) and control groups (n=22). The training group participated in a 12-week, individually t…

Effects of a progressive aquatic resistance exercise program on the biomechanical composition and morphology of cartilage in women with mild knee osteoarthritis: protocol for a randomised controlled trial

Background. Symptoms associated with osteoarthritis of the knee result in decreased function, loss of working capacity and extensive social and medical costs. There is a need to investigate and develop effective interventions to minimise the impact of and even prevent the progression of osteoarthritis. Aquatic exercise has been shown to be effective at reducing the impact of osteoarthritis. The purpose of this article is to describe the rationale, design and intervention of a study investigating the effect of an aquatic resistance exercise intervention on cartilage in postmenopausal women with mild knee osteoarthritis. Methods. A minimum of 80 volunteers who meet the inclusion criteria will…

Effects of progressive aquatic resistance training on symptoms and quality of life in women with knee osteoarthritis: A secondary analysis.

Abstract Objective: To conduct a secondary analysis to study the effects, those 4 months of aquatic resistance training have on self‐assessed symptoms and quality of life in post‐menopausal women with mild knee osteoarthritis (OA), after the intervention and after a 12‐month follow‐up period. Methods: A total of 87 post‐menopausal volunteer women, aged 60‐68 years, with mild knee OA were recruited in a randomized, controlled, 4‐month aquatic training trial (RCT) and randomly assigned to an intervention (n = 43) and a control (n = 44) group. The intervention group participated in 48 supervised aquatic resistance training sessions over 4 months while the control group maintained their usual l…

Efficacy of progressive aquatic resistance training for tibiofemoral cartilage in postmenopausal women with mild knee osteoarthritis : a randomised controlled trial

Objective: To study the efficacy of aquatic resistance training on biochemical composition of tibiofemoral cartilage in postmenopausal women with mild knee osteoarthritis (OA). Design: Eighty seven volunteer postmenopausal women, aged 60-68 years, with mild knee OA (Kellgren-Lawrence grades I/II and knee pain) were recruited and randomly assigned to an intervention (n = 43) and control (n = 44) group. The intervention group participated in 48 supervised aquatic resistance training sessions over 16 weeks while the control group maintained usual level of physical activity. The biochemical composition of the medial and lateral tibiofemoral cartilage was estimated using single-slice transverse …

External rotation strength deficit after hip resurfacing surgery.

The aim was to assess the effect of resurfacing hip arthroplasty on hip muscle function, when, in the posterior approach, the piriformis tendon and outer rotators of the hip joint were divided. The unoperated side was used as a control.Thirty-three consecutive patients (mean age 55 years, 73% males) were operated using the posterior approach. Main outcome measures were isometric muscle strength of external and internal rotators and extensors of the hip and hip pain.Hip external rotation strength (p0.001) and leg extension strength (p0.001) were significantly lower on the operated side compared with the un-operated side prior to the surgery. On the operated side external rotation strength de…

Effects of progressive resistance training on physical disability among older community-dwelling people with history of hip fracture

Background and aims: Hip fracture is a common trauma in older people, and often leads to decreased muscle strength and increased physical disability. This randomized controlled trial examined whether three months of progressive resistance training (PRT) can reduce physical disability among older people with a history of hip fracture. Methods: A population-based sample of 60-85-year-old community-dwelling persons, with hip fractures sustained on average three years earlier, were enrolled in the study. Of 78 people participating in laboratory assessments, those without contraindications for participation in resistance training were randomly assigned to a training group (TG, n=22) or a control…

Physical inactivity and pain in older men and women with hip fracture history

Hip fracture patients often suffer from pain for several months after surgery. This may lead to physical inactivity and subsequent mobility limitation and disability. The purpose of this study was to investigate the association between severe musculoskeletal pain and the level of physical activity in older people with a history of hip fracture. Data were collected from 60- to 85-year-old (n = 78) community-dwelling people, 0.7–7.5 years after hip fracture. Physical activity was assessed with the Yale Physical Activity Survey (YPAS). According to the YPAS summary index distribution, the participants were divided into the physically inactive and physically active groups. Musculoskeletal pain …

Balance Confidence Was Associated With Mobility and Balance Performance in Older People With Fall-Related Hip Fracture: A Cross-Sectional Study

Abstract Portegijs E, Edgren J, Salpakoski A, Kallinen M, Rantanen T, Alen M, Kiviranta I, Sihvonen S, Sipila S. Balance confidence was associated with mobility and balance performance in older people with fall-related hip fracture: a cross-sectional study. Objective To study the relationship between balance confidence, a concept closely related to fear of falling, mobility and balance performance, and perceived mobility limitation in older people after a fall-related hip fracture. Design Cross-sectional analyses of pretrial data of 2 randomized controlled trials of physical rehabilitation. Setting University research center. Participants Community-dwelling people aged over 60 years, 6 week…

Lower-Limb Pain, Disease, and Injury Burden as Determinants of Muscle Strength Deficit After Hip Fracture

Background: Hip fracture may result in an asymmetrical lower-limb strength deficit. The deficit may be related to the trauma, surgical treatment, pain, or disuse of the fractured limb. However, disease and injury burden or musculoskeletal pain in the other limb may reduce muscle strength on that side, reducing the asymmetrical deficit. The aim of our study was to explore the asymmetrical strength deficit and to determine the potential underlying factors in patients from six months to seven years after a hip fracture. Methods: The asymmetrical deficit was calculated ([fractured limb/sum of both lower limbs] x 100%) for isometric knee extension torque, rate of force development during isometr…

Sense of coherence: effect on adherence and response to resistance training in older people with hip fracture history.

Our aim was to study the effects of sense of coherence (SOC) on training adherence and interindividual changes in muscle strength, mobility, and balance after resistance training in older people with hip fracture history. These are secondary analyses of a 12-week randomized controlled trial of progressive resistance training in 60- to 85-year-old community-dwelling people 0.5–7 years after hip fracture (n = 45; ISRCTN34271567). Pre- and posttrial assessments included SOC, knee extension strength, walking speed, timed up-and-go (TUG), and Berg Balance Scale (BBS). Group-by-SOC interaction effects (repeated-measures ANOVA) were statistically significant for TUG (p = .005) and BBS (p = .040), …

Balance Confidence and Functional Balance in Relation to Falls in Older Persons with Hip Fracture History

PURPOSE: To investigate whether self-assessed balance confidence and functional balance are associated with falls in older persons with hip fracture history. METHODS: This study is a part of a larger study on functional capacity and exercise rehabilitation in hip fracture patients. Seventy-nine patients, operated at the local hospital for collum or trochanter fracture within one-half to 7 years, participated in the laboratory measurements. Balance confidence was assessed with Activities-specific Balance Confidence scale (ABC) and functional balance using the Berg Balance Scale (BBS). According to self-reported number of falls during the previous 6 months participants were classified as thos…

Bone mineral density of the proximal femur after hip resurfacing arthroplasty: 1-year follow-up study

Abstract Background Hip resurfacing arthroplasty (HRA) is considered a bone-preserving procedure and may eliminate proximal femoral stress shielding and osteolysis. However, in addition to implant-related stress-shielding factors, various patient-related factors may also have an effect on bone mineral density (BMD) of the proximal femur in patients with HRA. Thus, we studied the effects of stem-neck angle, demographic variables, and physical functioning on the BMD of the proximal femur in a one-year follow-up. Methods Thirty three patients (9 females and 24 males) with a mean (SD) age of 55 (9) years were included in the study. BMD was measured two days and 3, 6, and 12 months postoperative…