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Kumpletong Pagpapalit ng Siko (Arthroplasty)

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Pagbawi pagkatapos ng kabuuang palitan ng siko: banayad na tulong sa paggalaw gamit ang simpleng sling sa maagang yugto, ang isang functional na arc ng paggalaw bilang layunin, at isang permanenteng limitasyon sa pag-angat habambuhay upang maprotektahan ang implant.

Illustrasyon ng kabuuang palitan ng siko, na may mga metal na tangkay na nakapaloob sa buto ng itaas na braso at forebraso, na nakakonekta sa pamamagitan ng isang sentral na bisagra.
Isang semi-constrained (hinged) total elbow replacement, na may mga stem sa humerus at ulna na pinagsamang may isang linking hinge. Kieran Hirpara 4.0

Ang pahinang ito ay isinalin ng makina at hindi pa nasusuri ng isang doktor. Ang bersyong Ingles ang siyang opisyal.

Ang protokol na ito ay gabay sa iyong paggaling pagkatapos ng total elbow replacement (total elbow arthroplasty) kay Dr. Kieran Hirpara sa Mater Private Hospital Rockhampton. Nagsisimula ito sa iyong home exercise program, sinundan ng estrukturadong klinikal na protokol na isinulat para sa iyong physiotherapist o hand therapist: dalhin ang pahinang ito o ang PDF nito sa iyong unang bisita sa therapy upang manatiling koordinado ang iyong rehabilitasyon. Maaaring baguhin ng iyong therapist ang plano depende sa pag-unlad ng iyong paggaling.

Kung mayroon kang anumang alalahanin tungkol sa iyong sugat pagkatapos ng operasyon, makipag-ugnayan sa mga kwarto. Karaniwang makakatulong na kumuha ng litrato ng sugat at ipadala ito sa pamamagitan ng email para sa pagsusuri.

Ano ang inaasahan

Ang kabuuang palitan ng siko (total elbow replacement) ay nag-aalis ng mga nasira o sira na ibabaw ng kasu-kasuan sa siko at pinalitan ito ng implantong metal at plastik. Ang dalawang kalahati (isa ay nakakabit sa buto ng iyong itaas na braso, humerus, at isa naman sa buto ng iyong babaeng braso, ulna) ay karaniwang pinagsasama ng isang maliit na bisagra, kaya ito ay tinatawag na semi-constrained o "linked" na palitan. Ito ay karaniwang ginagawa para sa matinding rheumatoid arthritis, para sa osteoarthritis sa huling yugto, o para sa ilang mga fracture ng siko sa mga mas nakatatandang pasyente kung saan hindi na maayos ang buto.

Ang layunin ng iyong paggaling ay upang mapahinahon ang siko, protektahan ang mga nagpapagaling na tisyu, at muling makakuha ng isang komportableng, walang sakit na functional arc ng galaw (sapat na pagliko at pagtuwid upang mapadali ang mga pang-araw-araw na gawain tulad ng pagkain, paghuhugas, at paghahanda ng damit) imbes na gawing pinakamalakas na posible ang siko. Para sa pamamahala ng sugat, pamamaga, at peklat, tingnan ang gabay ng klinika tungkol sa wound care.

Ang pinakamahalagang bagay na unawain ay ito: ang implantong ito ay dinisenyo para sa komportableng pang-araw-araw na pamumuhay, hindi para sa mabibigat na trabaho. Ang mga pangunahing kaaway nito sa pangmatagalang panahon ay ang pagkasira ng plastik na bearing at ang unti-unting pagkaluwag ng implantong sa loob ng buto, at parehong ito ay dulot ng mabibigat na paggamit. Dahil dito, hindi angkop ang matinding programa ng pagpapalakas ng kalamnan pagkatapos ng kabuuang palitan ng siko, at ang limitasyon sa pag-angat ay mananatili sa iyo sa buong buhay, hindi lamang habang nagpapagaling. Ang pagsunod sa limitasyong ito ang pinakamahalagang bagay na maaari mong gawin upang matagal ang iyong bagong siko.

Magkakaroon ka ng simpleng sling para sa komportableng pagkatapos ng operasyon, hindi isang matigas na splint o brace. Ang banayad na tulong sa paggalaw ay magsisimula sa loob ng unang linggo, at ang plano ay unti-unti at maingat na binubuo mula doon.

Mga Pag-iingat at Limitasyon

Gawin:

  • Suotin ang simpleng sling para sa kaginhawaan, at gamitin ito ayon sa payo.
  • Simulan ang mga banayad na nakakatulong na galaw sa ibaba sa loob ng unang linggo, ayon sa gabay ni Dr. Hirpara at ng iyong terapeuta.
  • Panatilihing gumagalaw ang iyong kamay, pulso, at balikat upang maiwasan ang pagkasikip.
  • Sundin ang habambuhay na limitasyon sa pag-angat (sa ibaba) pagkatapos mong mabawi.

Huwag:

  • Huwag mag-angat ng anumang bagay na mas mabigat kaysa humigit-kumulang isang tasa ng tsaa (1 lb / 0.45 kg) gamit ang operadong braso sa loob ng unang 6 linggo.
  • Huwag pilitin ang pagbaluktot ng iyong siko, at huwag itong pukpukin o itulak na tuwid.
  • Huwag itulak upang tumayo mula sa upuan gamit ang operadong braso, dalhin, itulak, o ibigay ang iyong timbang sa pamamagitan nito, o hayaang hilahin o i-twist ito ng sinuman.
  • Kung ang triceps muscle ay itinulak pataas noong operasyon, huwag aktibong tuwidin ang siko laban sa resistensya hanggang sa ipahintulot ng iyong doktor (karaniwang 6–12 linggo).
  • Permanenteng, habambuhay na limitasyon: huwag paulit-ulit na mag-angat ng higit sa humigit-kumulang 2 kg, at huwag mag-angat ng higit sa humigit-kumulang 4.5–5 kg sa isang pagsisikap. Ang mga limitasyong ito ay permanenteng habambuhay. Walang tennis, pagtapon, o mga sports na may epekto, sa anumang panahon.

Ang iyong mga ehersisyo

Ito ang mga ehersisyo mula sa iyong handout, para sa dahan-dahang pagbawi ng galaw ng iyong siko, forearm, pulso at kamay. Simulan ang mga ito ayon sa gabay ni Dr. Hirpara at ng iyong terapeuta. Panatilihing dahan-dahan at walang pilitan ang bawat galaw; sa unang yugto, ang layunin ay madali at tulong-galang na paggalaw, hindi pagsisikap o pag-unat.

Ang iyong klinikal na protokol

Ang natitirang bahagi ng pahinang ito ay ang klinikal na protokol para sa rehabilitasyon pagkatapos ng semi-constrained total elbow replacement (posterior approach, inaasumang triceps-sparing). Ang seksyong ito ay dapat ibigay sa iyong physiotherapist o hand therapist, at bawat yugto sa ibaba ay nagsisimula sa isang simpleng paliwanag sa wikang Ingles tungkol sa nangyayari.

Bago ang paggamot, suriin ang operation report at kasaysayan ng medikal na kalagayan ng pasyente, at makipag-ugnayan sa treating surgeon tungkol sa surgical approach, partikular kung ang triceps ay na-spare, na-reflected, o na-reattach (Bryan–Morrey), dahil ito ang nagtatakda ng mga restriction sa maagang extension at resting position.

Yugto I — Agad na post-surgical, linggo 0–6

Sa unang anim na linggo, ang pokus ay ang pagprotekta sa mga gumagaling na malambot na tisyu at sa triceps, pagpapahupa ng sugat at pamamaga, at pagsisimula ng banayad na assisted motion upang hindi mahigpit ang siko. Ginagamit ni Dr. Hirpara ang simpleng sling para sa kumportableng suporta, hindi posterior splint o brace. Ang banayad na assisted (active-assisted) pagliko at pagwawasto ng siko ay nagsisimula sa pagitan ng araw 1 at 7, habang hawak ang siko sa gilid at ang forearm ay nasa neutral-to-pronated na posisyon, gamit ang gravity upang matulungan ang pagwawasto. Walang pag-angat ng mas mabigat kaysa 1 lb (0.45 kg) gamit ang operated na braso, at walang weight-bearing o pagtulak sa pamamagitan nito.

Para sa iyong physiotherapist:

Immobilisasyon at mga paalala

  • Simpleng sling para sa kumportableng suporta (praktika ni KH: walang posterior splint o brace). Kung gumamit ng brace o splint ang surgeon dahil sa alalahanin sa malambot na tisyu, sundin ang direksyon na iyon; kung hindi, ang simpleng sling ay isusuot ng humigit-kumulang anim na linggo, at tinatanggal lamang para sa mga ehersisyo at hygiene.
  • Mga kaso ng triceps-reflected / reattached (hal. Bryan–Morrey): i-immobilise malapit sa extension, at iwasan ang aktibo at resisted elbow extension sa maagang yugto upang maprotektahan ang repair (cf. distal-triceps-repair logic).
  • Walang forced flexion (nagpapataas ng stress sa triceps repair) at walang biglaan o forced extension.
  • Walang upper-limb weight-bearing, walang pagtulak laban sa resistance, walang varus/valgus stress.
  • Walang pag-angat ng mga bagay na > 1 lb (0.45 kg) gamit ang operated na braso.

Mga Ehersisyo

  • Banayad na active-assisted ROM (AAROM) elbow flexion/extension mula araw 1–7, ang siko ay adducted sa gilid, ang forearm ay nasa neutral-to-pronated na posisyon; gravity-assisted extension stretch.
  • Aktibong range of motion para sa kamay, pulso, at balikat upang maiwasan ang pagkahigpit.

Mga pamantayan upang makapagpatuloy sa Yugto II: gumaling na ang sugat, kontrolado na ang sakit, at nakapagtapos na ng banayad na AAROM. Huwag magpatuloy sa strengthening bago ang 6 linggo.

Yugong II — Gawain na pang-funksyon, mula sa 6 linggo (hindi bago pa)

Nagsisimula ang yugong ito sa banayad na pag-activate ng kalamnan at, sa huli, napakagaan na pagpapalakas, ngunit hindi kailanman isang matapang na programa. Binubuo ang galaw patungo sa isang functional arc, at dahan-dahan at magaan lamang ipinakilala ang resistensya. Patuloy na ipinapatupad ang pag-iwas sa pag-angat ng mabigat na bagay sa buong yugong ito.

Para sa iyong pisyoterapeuta:

Takdang-oras sa loob ng Yugong II

  • 6 linggo: magsimula sa submaximal, walang sakit na isometrics sa gitnang hanay, sa lahat ng mga plano. Kung ang triceps ay na-reflected/na-reattach, kumpirmahin na pinapayagan ito bago idagdag ang extension isometrics.
  • 8 linggo: umusad sa multi-angle na submaximal na isometrics, iwasan ang end-range.
  • 10–12 linggo: ipakilala ang magaan na isotonic strengthening (walang mga timbang o resistensya na > 5 lb (2.3 kg)), unang single-plane, pagkatapos ay composite.

Layunin sa Range-of-motion

  • Functional arc: 30–120/130° flexion, kasama ang 60° pronation at 60° supination.
  • Kung ang flexion ay < 120° sa 10–12 linggo, isaalang-alang ang dynamic o static-progressive splint.

Mga Paalala

  • Patuloy na iwasan ang mabigat na paglo-load, pagtulak at impact.
  • Pilosopiya sa pagpapalakas (verbatim): "Hindi angkop ang pangangailangan para sa isang matapang na programa ng pagpapalakas pagkatapos ng total elbow arthroplasty."

Mga Kriteryo upang umusad: nakamit at pinapanatili ang isang walang-sakit na functional arc.

Huling Yugto II at buong-buhay, mula sa 12 linggo

Mula sa humigit-kumulang 12 linggo, ang siko ay lilipat sa isang maintenance home program upang panatilihin ang pain-free functional arc. Walang pormal na mabigat na pagpapalakas, kahit kailan. Ang mga limitasyon sa aktibidad at pag-angat sa buong-buhay na ito ay magiging permanenteng aplikado na.

Para sa iyong physiotherapist:

  • Home program upang mapanatili ang pain-free functional arc.
  • Palakasin ang permanenteng mga limitasyon sa aktibidad sa pasyente.
  • Isaalang-alang ang discharge kapag naabot na ang isang stable, komportableng functional arc at ang angkop na pagbabalik ng pang-araw-araw na gawain.

Pagbabalik sa trabaho at gawain

Ang iyong bagong siko ay dinisenyo para sa komportableng pang-araw-araw na pamumuhay, at ang mga limitasyong nasa ibaba ay permanenteng balakid; ito ang nagpapahaba sa buhay ng implant.

  • Pagbuhat (sa buong buhay): huwag paulit-ulit na buhatin ang higit sa humigit-kumulang 2 kg (dalawang punong tasa), at huwag buhatin ang higit sa humigit-kumulang 4.5–5 kg sa isang pagtatangkang pagsisikap (katumbas ng isang punong kettle), gamit ang operadong braso, sa anumang panahon. Sa unang 6 linggo, mas mahigpit ang limitasyon: walang mabibigat na higit sa humigit-kumulang 1 lb (0.45 kg).
  • Isports at impact: walang tennis, pagtapon, o pag-load ng impact sa anumang panahon, sa buong buhay. Pinapayuhan ang magaan, low-load na mga gawain kapag pinapayagan na, ngunit ang siko ay hindi dapat mabigatan o matamaan.
  • Pagmamaneho: muling magsimula lamang kapag komportable ka na, nasa labas ng sling para sa pagmamaneho, at kayang kontrolin ang manibela nang ligtas. Kumpirmahin ang oras kasama si Dr. Hirpara sa iyong review.
  • Trabaho: ang magaan na trabaho sa desk at mga gawain sa sariling pag-aalaga ay muling magsisimula nang maaga, hangga't komportable ka. Ang anumang tungkulin na nangangailangan ng pagbuhat, pagdadala, pagtulak, o paulit-ulit na pag-load ng braso ay dapat talakayin nang indibidwal kasama si Dr. Hirpara, dahil ang mga limitasyong panghabambuhay ay kailangang sundin rin sa trabaho.

Ang pagsunod nang tapat sa mga limitasyong ito ang pinakamahalagang bagay na maaari mong gawin upang protektahan ang iyong palitan at maiwasan ang pag-loosen o pagkasira sa loob ng mga taon.

Pagkatapos ng iyong protocol

Ang protocol na ito ay nagtatrabaho kasama ng pangkalahatang payo para sa paggaling ng klinika; tingnan ang pamamahala ng sakit pagkatapos ng operasyon at pag-aalaga sa sugat. Ang iyong patuloy na paggaling ay indibidwal na pinamumunuan ng iyong pisyoterapeuta o hand therapist ayon sa pag-unlad ng iyong siko, at ang mga limitasyon sa iyong aktibidad habambuhay ay dapat tandaan sa bawat pagsusuri.

Reviewed by Dr Kieran Hirpara · 18 June 2026.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Total Elbow Arthroplasty (TEA) — Rehabilitation Evidence

Topic scope: post-operative rehabilitation after semi-constrained (linked/hinged) total elbow replacement — most commonly for rheumatoid arthritis, end-stage osteoarthritis, or a non-reconstructable distal humerus fracture in an elderly patient. This brief covers the phased rehabilitation timeline, the early triceps-protection rationale, the functional-arc goal, and — critically — the lifelong lifting restriction that exists to protect the implant against polyethylene wear and aseptic loosening.

Defining principle: unlike most joint replacements, the goal of TEA rehabilitation is a pain-free functional arc (~30–130° flexion, 60°/60° rotation), not maximal strength. The implant's long-term enemies are polyethylene wear and aseptic loosening, both driven by load, so heavy loading is restricted permanently, not just during healing — "the need for a vigorous strengthening program is not appropriate following total elbow arthroplasty." Dr Hirpara's practice: a simple sling for comfort (not a posterior splint or brace), gentle active-assisted motion from day 1–7, isometrics from ~6 weeks, light isotonic (≤ 5 lb) from 10–12 weeks, triceps protection where the triceps was reflected or detached, and a lifelong lifting limit (no repetitive lift > ~2.3 kg; no single lift > ~4.5–5 kg; no tennis/throwing/impact ever).

Consensus phased timeline (week windows)

Anchored to the Brigham & Women's Hospital (BWH) Total Elbow Arthroplasty Protocol (Thornhill; semi-constrained, hinged/linked prosthesis; posterior triceps-sparing approach assumed) and cross-checked against the primary literature. Dr Hirpara's practice substitutes a simple sling for comfort in place of BWH's 60° posterior resting splint; the ROM and strengthening cadence and the lifelong limits are retained.

Phase Window Sling / immobilisation ROM and use Strengthening Lifting
I — Immediate post-surgical Weeks 0–6 Simple sling for comfort (KH — no posterior splint/brace); triceps-reflected cases immobilised nearer extension Gentle AAROM flexion/extension from day 1–7, elbow adducted, forearm neutral-to-pronated, gravity-assisted extension; hand/wrist/shoulder AROM None No lifting > 1 lb (0.45 kg); no weight-bearing/pushing
II — Functional activity From 6 weeks (not before) Sling weaned 6 wk: submaximal mid-range isometrics, all planes · 8 wk: multi-angle submaximal isometrics (avoid end-range) · target functional arc 30–120/130°, 60°/60° 10–12 wk: light isotonic, no resistance > 5 lb (2.3 kg), single-plane → composite Restriction continues
Late II / lifelong 12 weeks onward — Maintain pain-free functional arc No vigorous strengthening — ever Lifelong limits apply (see below)

Triceps-protection note. Where the triceps is reflected (Bryan–Morrey) rather than spared, early rehabilitation is stricter — immobilisation nearer extension and delayed/limited active and resisted extension to protect the reattachment (cf. distal-triceps-repair logic). Wiesel keeps the elbow in full extension ~24–36 h then begins active-assisted ROM, and adds no pushing/overhead for 3 months to protect the triceps; Wolfe & Ranawat's osteo-anconeus flap is immobilised ~16 days. Triceps insufficiency is a recognised TEA complication.

CRITICAL — lifelong lifting restriction numbers + sources

Source Repetitive limit Single-event limit Lifelong?
BWH Standard of Care (Thornhill) no repetitive lifts > 5 lb no single lift > 15 lb yes — "no heavier than 15 lb for life"; "no tennis or throwing for life"
Wiesel, Operative Techniques in Orthopaedic Surgery (2011) > 5 lb (~2.3 kg) > 10 lb (~4.5 kg) yes (also no pushing/overhead × 3 months to protect triceps)
Toulemonde et al., Int Orthop 2015 (100 semi-constrained TEA) > 1 kg 5 kg yes; all weight-lifting avoided entirely for the first 3 months
Kumar & Mahanta, Indian J Orthop 2013 — 5 kg permanent restriction of strenuous activity

Bottom line / patient-facing range: the canonical teaching is a lifelong restriction of roughly ~5 lb (2.3 kg) repetitive and ~10–15 lb (4.5–5 kg) single event. The exact ceiling varies by source: BWH allows up to 15 lb once; Wiesel caps single lift at 10 lb; the European series (Toulemonde) is most conservative at 1 kg repetitive / 5 kg single. Dr Hirpara quotes the conservative patient-facing range: do not repetitively lift more than ~2 kg, or lift more than ~5 kg in a single event, for life; no tennis/throwing/impact ever.

Key controversies / evidence quality

  • Lifting-limit variation. Numbers range from 1 kg / 5 kg (Toulemonde 2015) to 5 lb / 15 lb (BWH). The restriction exists to protect against polyethylene wear and aseptic loosening, the dominant long-term failure mode — hence its permanence.
  • Triceps-sparing vs reflected approach. Surgical handling of the triceps dictates early rehab: triceps-sparing (BWH default) permits earlier gentle AAROM; reflected approaches require protecting the reattachment with immobilisation nearer extension and delayed active/resisted extension. Triceps insufficiency/weakness is a recognised complication.
  • Longevity and compliance. TEA was historically reserved for elderly low-demand patients owing to implant-longevity concerns (survivorship ~85–96% at 5 y, ~70–92% at 10 y in RA). As indications expand to younger, more active and post-traumatic patients, non-compliance with activity limits drives higher complication and failure rates — which is precisely why the lifelong limit is emphasised to every patient.

Evidence strength flags

  • MODERATE–STRONG (published protocol + restriction numbers): the BWH institutional Standard of Care provides an explicit phased timeline with verbatim lifting limits, independently corroborated by multiple peer-reviewed primary sources (JBJS, JHS, JSES, Int Orthop, JAAOS) for the lifelong restriction and the triceps-protection rationale.
  • MODERATE (ROM / strengthening cadence): phase timings and the isometric → light-isotonic progression are consensus/expert-driven; no high-level RCT dictates the rehab cadence. The exact lifting ceiling varies by source.
  • CONSENSUS: the simple-sling (vs posterior-splint) choice and the precise functional-arc targets reflect surgeon practice and institutional protocols rather than trial data.

CITATIONS

RAG corpus (180,000+ Orthopaedic articles)

  • Toulemonde J, Ancelin D, Azoulay V, et al. Complications and revisions after semi-constrained total elbow arthroplasty: a mono-centre analysis of 100 cases. Int Orthop. 2015. (1 kg repetitive / 5 kg single; no weight-lifting first 3 months)
  • Kumar S, Mahanta S. Primary total elbow arthroplasty. Indian J Orthop. 2013. (5-kg weight-lifting restriction)
  • Schoch B, Wong J, Abboud J, et al. Results of total elbow arthroplasty in patients less than 50 years old. J Hand Surg Am. 2017. (longevity/survivorship driving the restriction)
  • Seitz WH, Evans PJ, Bismar H, Peers S. Complications of total elbow arthroplasty in nonrheumatoid patients. J Hand Surg Am. 2014. (active patients, poor compliance → complications)
  • Baghdadi YM, Veillette CJ, Malone AA, et al. Total elbow arthroplasty in obese patients. J Bone Joint Surg Am. 2014;96(9). (higher failure with high BMI)
  • Barlow JD, Morrey BF, O'Driscoll SW, et al. Activities after total elbow arthroplasty. J Shoulder Elbow Surg. 2013;22(6):787–791.
  • You D, King G, Dehghan N, et al. Optimizing outcomes in total elbow arthroplasty. J Am Acad Orthop Surg (JAAOS). 2025. (modern failure-reduction review)
  • Burnier M, Nguyen NTV, Morrey ME, et al. Revision elbow arthroplasty using a proximal ulnar allograft with allograft triceps for combined ulnar bone loss and triceps insufficiency. J Bone Joint Surg Am. 2020;102(22). (triceps insufficiency complication)
  • Na K, Song S, Lee Y, et al. Modified triceps fascial tongue approach for primary total elbow arthroplasty. J Shoulder Elbow Surg. 2018;27(5):887–893. (triceps weakness after TEA; approach effect)
  • Wolfe SW, Ranawat CS. The osteo-anconeus flap: an approach for total elbow arthroplasty. J Bone Joint Surg Am. 1990;72(5). (triceps-continuity-preserving approach; ~16-day immobilisation)
  • Ring D. Instability after total elbow arthroplasty. Hand Clin. 2008. (triceps/LCL reattachment and stability)
  • Wiesel SW. Operative Techniques in Orthopaedic Surgery. 2011. (5 lb repetitive / 10 lb single; full-extension splint 24–36 h; no pushing/overhead × 3 months to protect triceps)

Published protocol (web)

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l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

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

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

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

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

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

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

ii. a copyright notice;

iii. a notice that refers to this Public License;

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

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

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

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

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

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

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

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

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

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

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

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

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

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

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

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

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

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

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

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

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

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

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

Section 8 -- Interpretation.

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

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

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.