Early Weight Bearing Research Articles

Comparison of locking compression plate and distal femoral replacement for periprosthetic distal femoral fractures: a retrospective study.

ObjectiveTo compare the clinical outcomes of locking compression plate (LCP) and distal femoral replacement (DFR) for periprosthetic distal femoral fractures (PDFFs) after total knee arthroplasty.MethodsThis retrospective study identified patients with PDFFs in an institutional database between January 2012 and December 2021. Demographic data and clinical outcomes, including postoperative complications, reoperation, 1-year mortality, Knee Society Scores (KSS) and Knee Society Functional Score (KSFS) were analysed.ResultsIn total, 12 patients treated with LCP and six patients treated with DFR were included. There was no significant difference between the LCP and DFR groups in terms of postoperative complications (25.0% versus 33.3%, respectively), reoperation (8.3% versus 0.0%), respectively, 1-year mortality (8.3% versus 16.7%, respectively) or mean ± SD KSS (80.3 ± 8.3 versus 78.0 ± 2.5, respectively). However, the mean ± SD KSFS was significantly better for patients with LCP than for those with DFR (51.8 ± 12.5 versus 37.0 ± 6.7, respectively).ConclusionDFR provides similar clinical outcomes compared with LCP for PDFFs. Patients with advanced age may benefit from DFR to allow early weight bearing.

Results of an Interim Analysis of a Prospective Multicenter Study Assessing Radiographic and Patient Outcomes Following Triplanar Tarsometatarsal Arthrodesis with Early Weightbearing

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The majority of hallux valgus corrections are performed via a two dimensional approach with 1st metatarsal osteotomy and translation in the transverse plane. This approach has demonstrated high long-term recurrence rates. Recent research demonstrates that 87% of hallux valgus deformities are three-dimensional with abnormal frontal-plane rotation of the metatarsal, which cannot be completely addressed with a two dimensional metatarsal osteotomy alone. While correction at the 1st tarsometatarsal (TMT) joint may provide the optimal surgical approach for 3D anatomic restoration at the apex of the deformity, 1st TMT fusion historically entails an extended period of non-weightbearing. This study evaluated the clinical, radiographic, and patient-reported outcomes in patients undergoing instrumented triplanar 1st TMT arthrodesis (TMTA) with a biplanar plating system and protected near-immediate weightbearing. Methods: This is a prospective multicenter study that will continue for 60 months post-operatively. Patients between 14-58 years old with symptomatic hallux valgus (intermetatarsal and hallux valgus angles between 10.0-22.0° and 16.0-40.0°, respectively) and no prior hallux valgus surgery on the operative foot were eligible for this study. Patients were treated with an instrumented TMTA procedure using a biplanar plating system with protected near-immediate weightbearing. Several outcomes (radiographic, return to weightbearing and activities, pain measured by visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOxFQ), and Patient Reported Outcomes Measurement Information System (PROMIS)) were evaluated post-operatively. Two independent fellowship trained musculoskeletal radiologists reviewed all radiographic data. These interim results are limited to patients completing at least 6 months of follow-up. Results: 165 patients underwent TMTA with at least 6 months follow-up (mean (SD): 17.8 (7.7); min, max: 5.8, 37.3). Mean age was 41.0 (range:14-58) years; 91.5% of patients were female. Mean (SD) days to protected weightbearing in CAM boot and return to full work were 8.4 (7.7) and 56.8 (45.6), respectively. Significant improvements from baseline in HVA, IMA, and TSP (Table 1), VAS score, MOxFQ and PROMIS domains were observed as early as 6 weeks post-procedure. At 12 months, mean (95% CI) change in VAS was -3.7(-4.0, -3.3); Walking/Standing (MOxFQ) change was -35.2 (-39.6, -30.8); and Physical Function (PROMIS) change was 8.7 (7.1, 10.3). Fifteen (9.1%) patients experienced hardware complications, yet maintained radiographic correction to date. No patients (0/58) with 24 months follow-up have experienced recurrence. Conclusion: These interim findings support that TMTA with biplanar plating is successful in correcting the 3D hallux valgus deformity with early return to weightbearing while demonstrating favorable clinical and patient-reported outcomes. Patients exhibited meaningful pain reduction after surgery and were able to return to full, unrestricted work and activities in less than two months, on average. Statistically significant improvements in patients' health-related quality of life were observed at 6 and 12 months, post-operatively. Patients will continue to be followed for up to 60 months with additional evaluations for complications, 24-month recurrence, and patient satisfaction.

Tibial condylar valgus osteotomy for the treatment of intra-articular varus deformity of the knee.

The increasing incidence and distribution of primary and post-traumatic knee osteoarthritis (OA) in the young, active population has renewed interest in joint-preserving procedures. High tibial osteotomy (HTO) represents the most common treatment for medial knee OA associated with varus tibial deformity. However, deformities may also be related to intra-articular defects that an extra-articular procedure could not correct. The tibial condylar valgus osteotomy (TCVO) represents an intra-articular surgical technique for treating advanced medial knee OA with lateral joint subluxation. Currently, only a few papers with small samples and limited follow-up report the use of TCVO for the treatment of intra-articular deformities. Indications and operative techniques are various and not standardized. After an extensive search of PubMed, Scopus and Cochrane library, the main purpose of this paper is to summarize and discuss the indications, surgical techniques, and outcomes of intra-articular osteotomies while also reporting the preoperative planning and surgical procedure performed at our institution. These characteristics allow earlier weight-bearing and faster complete recovery. TCVO is an effective procedure to correct lower limbs' intra-articular defects from degenerative conditions developmental and post-traumatic deformities. This surgical technique, working at the intra-articular level, leads to some benefits related to restoring joint congruence and stability by realigning the axis of the lower limb and reducing the lateral joint subluxation. Moreover, the improved valgisation and lateralization of the mechanical axis and the limitation of the osteotomy to the medial condyle led to a better load distribution to the not osteotomy-involved compartment.

The Effect of Diabetes on Ankle Fracture Outcomes in the UK: A National Collaborative Assessment of Current Guidelines, Management and Surgical Choices in Ankle Fractures

Category: Trauma; Ankle Introduction/Purpose: Objectives: Ankle fractures associated with diabetes experience more complications with standard Open-Reduction-Internal-Fixation (ORIF) following AO-principles than those without diabetes. It is unclear if augmented/extended fixation strategies can improve this. This aim of this study was to understand utilisation of extended/augmented/ORIF techniques (e.g., hind-foot-nail (HFN) and present outcomes of ankle fractures associated with diabetes. Secondarily the study aimed to evaluate compliance with national guidelines on early post-operative weight bearing. Methods: Research, Design & Methods: A national-multicentre retrospective cohort study was conducted between Jan - Jun 2019 of 56 UK centres (10 Major-Trauma-Units and 46 Trauma-Units). Institutional approval was obtained by all centres. 1360 complex-ankle-fractures were enrolled. Demographics, fixation choice and surgical outcomes were obtained. Statistical analysis was performed including propensity matching comparing patients with and without diabetes. Results: 316pts (23.2%) had diabetes, 7.4% had neuropathy, with a mean age 63.9yrs (vs.49.3yrs in non-diabetes), with greater frailty >4 (24% vs.14% (non-diabetes) (p<0.03). 79.7% underwent standard AO-principles-ORIF; those with peripheral neuropathy were more likely to undergo extended/augmented-techniques. Overall wound complications were higher with diabetes (15.8% vs. 8.8% (p<0.02). 13% of patients with diabetes underwent augmented/extended techniques without a difference in complications to a matched control group without diabetes. Conclusion: Diabetic ankle fractures occur in older, frailer persons; whilst lower than expected neuropathy rates suggest a need for improved assessment. Contrary to current guidelines most patients remain non-weightbearing post-surgery. Extended/Augmented surgical techniques can allow earlier weight-bearing without increasing complications. MDT screening/management may improve surgical selection and under-utilisation of these techniques and promote early mobilisation.

Durability and Safety of Deep Peroneal Nerve Neurectomy for Midfoot Arthritis at Midterm Follow Up

Category: Midfoot/Forefoot Introduction/Purpose: Midfoot osteoarthritis affects up to 12% of the adult population greater than 50 years old. Arthrodesis is the traditional surgical procedure performed when nonoperative management fails but is a technically demanding procedure that requires prolonged postoperative immobilization and is not uncommonly complicated by nonunion or deep infection. The deep peroneal nerve (DPN) plays a significant role in afferent nociceptive midfoot joint pain perception, most consistently in the second and third tarsometatarsal joints and the naviculocuneiform joint. Early outcomes following DPN neurectomy have demonstrated promising results as a safe and effective treatment that allows early mobilization and weight bearing. The purpose of our study was to evaluate the mid-term patient satisfaction and pain relief after DPN neurectomy for treatment of chronic midfoot pain due to osteoarthritis. Methods: In this retrospective IRB-approved questionnaire-based study, we evaluated 49 out of 95 patients identified (56 feet) with an average follow-up of 34.6 (range, 9 to 51) months, who underwent DPN neurectomy (Figure 1) at our institution between September 2017 and February 2021. There were 39 women and 10 men, 42 unilateral (23 right, 19 left) and 7 bilateral procedures, with an average age of 67.9 (range, 35 to 88) years at the time of surgery. A questionnaire which included questions regarding post-surgical dorsal midfoot pain relief, surgical result satisfaction, and current functional limitations was administered via telephone. Demographic information, patient responses, and complications were recorded. Results: There was an 81.2% patient satisfaction with the result of the surgery in relieving their dorsal midfoot pain. Of the 49 patients, 84.9% would repeat the surgery under the same circumstances, 84.1% would recommend the surgery to a friend, 10.2% reported they wish they had undergone arthrodesis, 8.2% reported no pain relief in the first 6 months, and 55.8% reported current activity limitations because of dorsal midfoot pain. Six feet (10.7%) underwent a second procedure with an average postoperative time of 20.5 (range, 1 to 36) months. Complications include one patient with deep wound infection, one DPN neurectomy revision and burial into bone, one DPN neuroma excision, one midfoot exostosis excision, and two conversions to arthrodesis. Theoretic complications of neuroarthropathy, midfoot collapse, and development of lesser toe deformities were not observed. Conclusion: DPN neurectomy is a safe and effective surgical option for the management of chronic dorsal midfoot pain due to midfoot osteoarthritis after failed nonoperative management. At midterm follow-up, patients who underwent dorsal midfoot denervation reported acceptable satisfaction rates, similar to those reported for arthrodesis, with associated improved functional outcomes and few complications.

Early weight bearing in elderly patients with ankle fractures reduces care needs and maintains independence

BackgroundAnkle fractures in the elderly are increasingly prevalent and are associated with significant morbidity and loss of independence. MethodPatients over the age of 70 suffering ankle fracture were identified using ICD-9-CM patient coding. Fracture stability was assessed using patient records and radiographic evidence. Management strategy, length of inpatient stay, time non-weight bearing, pre-admission residence, discharge destination and discharge care needs were studied. Results169 patients with a mean age 80.3 years were studied. Management strategy was shown to have a significant effect on a patient’s care requirements (p = 0.012) and ability to return to their primary residence (p = 0.014). Management via an intramedullary rod was associated with the lowest rates of increased care needs (29.7%) and the highest rate of returning home on discharge (88.9%). ConclusionsEarly weight bearing had a significant effect on a patient’s ability to maintain independent living and were more likely to return to their own home.

Percutaneous achilles tendon repair with absorbable suture: Outcomes and complications

ObjectiveThe purpose of this study is to evaluate the clinical outcomes and complications of percutaneous achilles tendon repair with absorbable sutures. Material and methodsA prospective cohort study including patients treated for an achilles tendon rupture from January 2016 to March 2019 was conducted. Inclusion criteria≥18 years of age, non-insertional (2–8cm proximal to insertion) achilles tendon ruptures. Open or partial ruptures were excluded. The diagnosis was based on clinical criteria and confirmed by ultrasonography in all patients. Epidemiological data, rupture and healing risk factors, previous diagnosis of tendinopathy, pre-rupture sport activity, job information, mechanism of rupture and the time in days between lesion and surgery were collected.Patients were assessed using visual analogue scale (VAS) at the 1, 3, 6 and 12-month follow-up. The achilles tendon rupture score (ATRS) were assessed at the 6 and 12 month follow-up. Ultrasound was performed at the 6-month follow-up. The re-rupture rate and postoperative complications were also collected. ConclusionsIn our experience, percutaneous achilles tendon repair with absorbable sutures in patients with an acute achilles tendon rupture has shown good functional results but with a high incidence of complications. Although most complications were transitory sural nerve symptoms, this complication would be avoided in patients treated conservatively. For this reason, conservative treatment associated with an early weightbearing rehabilitation protocol should be considered a viable option for patients with achilles tendon ruptures, mainly in cooperative young patients.

Masquelet's induced membrane technique associated with Reamer Irrigation Aspiration grafting and intramedullary Nailing (MaRIAN) for chronic diaphyseal osteomyelitis of the lower limb

IntroductionMasquelet's induced membrane technique offers a definitive contribution to the treatment of diaphyseal osteomyelitis. To overcome its drawbacks while maintaining its principles, technical modifications have been proposed: antibiotic cement, femoral intramedullary autograft harvested by RIA (Reamer Irrigation Aspiration) and interlocking nails. Material and methodThis retrospective study gathered patients with chronic osteomyelitis of the femur or tibia. The first surgical stage consisted of bone resection in the healthy zone and use of a gentamicin cement spacer to fill the bone defect. The second stage consisted of the placement of a statically locked intramedullary nail associated with a bone autograft using the RIA technique. ResultsAmong this group of 12 men with diaphyseal osteomyelitis; 9 tibial and 2 femoral, and 1 knee nonunion, the mean bone defect was 7.3cm (±6.7). The mean time between the 2 stages was 2.7months (±3) with a mean antibiotic period of 3.25weeks (±3). There was a femoral diaphyseal fracture at the donor site, and a wrong trajectory intraoperatively during the RIA. Two patients with tibial nonunion presented with nail rupture without septic recurrence. A septic recurrence was healed by removal of the nail. At a minimum follow-up of 18months, with an average of 5years, consolidation was complete without infectious recurrence. Despite the statistical weakness related to the size of the cohort, the resumption of early weight bearing (OR=−7.68 95% CI [−13.33 to −2.08] (p=0.01)) and nail dynamization seemed to have an impact on the formation of complete consolidation (OR=−0.86 95% CI [−1.39 to −0.33] (p=0.007)). Discussion and conclusionThis short series, compared to the literature, demonstrated that the proposed technical modifications improved the overall management of this rare and challenging condition while maintaining the reliability of the original technique. Dynamization was also seen to be of particular interest. Level of evidenceIV, retrospective study.

Accelerated rehabilitation program following medial patellofemoral ligament reconstruction does not increase risk of recurrent instability

BackgroundRehabilitation protocols following medial patellofemoral ligament (MPFL) reconstruction were historically restrictive, with patients often immobilized and/or given weightbearing restrictions. However, more recently published protocols have been more aggressive. We compared patient-reported outcomes and recurrent dislocation risk between patients treated with a restrictive rehabilitation program (early post-operative bracing and weightbearing restrictions) and an accelerated rehabilitation protocol (no post-operative bracing or weightbearing restrictions) following MPFL reconstruction. MethodsPatients who underwent isolated MPFL reconstruction at an academic center between 2008 and 2016 were identified. Patient demographics, anatomical measurements, surgical details, and outcomes were collected. During this period, the rehabilitation protocol at the center transitioned from a restrictive to an accelerated rehabilitation protocol. Failure risk and patient-reported outcomes were compared based on rehabilitation protocol. ResultsOf the163 isolated MPFL reconstructions performed during the study period, 123 (75%) were available for minimum one-year follow up at a mean of 4.0 years post-operative. Overall, 53 knees (43%) underwent the accelerated rehabilitation protocol and the remaining 70 knees (57%) underwent the restrictive protocol. There were 3 recurrent dislocations during the study period (2.4%), all of which occurred in the restrictive rehabilitation group. Multiple linear regression demonstrated that being in the accelerated rehabilitation group was not associated with poorer Knee injury and Osteoarthritis Outcome Score (KOOS) subscales controlling for age, sex, body mass index, Caton-Deschamps Index, tibial tubercle-trochlear groove distance, sulcus angle, MPFL graft choice, and length of follow-up. ConclusionAn accelerated rehabilitation protocol without immobilization or weightbearing restrictions does not increase risk of recurrent patellar dislocation or poorer patient-reported outcome following isolated MPFL reconstruction.

Management of Unstable Per-trochanteric Fracture in Old Patient by Primary Prosthetic Replacement

Background: Peritrochanteric fractures are frequent of the proximal femur and represents about half of all proximal femur fractures. They are associated with disability, mainly in elder patients. Its management aiming to achieve immediate ambulation and to regain the pre-operative ambulation.
 Aim and objectives; to evaluate and assess the functional and radiological outcomes of primary prosthetic replacement in old age cases of unstable per-trochanteric femur fractures,
 Subjects and methods: The current work was an interrupted time series clinical trial (quasi experimental), included 15 patients suffering from unstable per-trochanteric fracture presented to us within a week of sustaining injury. They were clinically assessed and checked for fitness for surgery. Then and after surgery, they were followed by for functional outcome by Harris Hip Scale and any complications were recorded.
 Results: Patients age ranged between 61 and 94 years. Females were more affected than males (80.0% vs 20.0%). Associated comorbidities were hypertension, diabetes and both conditions among 33.3%, 6.7% and 33.3%, successively. Falling was the commonest mode of injury (60.0%), and the left side was more affected than the right (60.0% vs 40.0%). Associated injuries were 1(6.7%) fracture surgical neck hummers, 1(6.7%) contralateral both bone leg fracture, 1(6.7%) had fracture mid shaft ulna. Regarding outcome, all cases were free from postoperative complications. However, blood loss was reported among 11(73.3%). Twelve (80%) patients had an excellent, 2 (13.3%) had good and 1(6.7%) had fair functional outcome. There was significant association between functional outcome and patients, gender, associated comorbid medical conditions, mode of trauma, side of trauma, or blood loss.
 Conclusion: Primary prosthetic replacement is a valid surgical option in management of unstable trochanteric fractures in elderly. The main advantages are the safety, effectiveness and early full weight bearing.

Effect of Accelerated Rehabilitation on Early Return to Sport After Arthroscopic Ankle Lateral Ligament Repair.

Background:Although the minimal invasiveness of arthroscopic ankle lateral ligament repair (ALLR) means that an early return to sporting activities can be anticipated, studies have described postoperative cast immobilization and the avoidance of weightbearing for a certain period. Accelerated rehabilitation may be helpful for an early return to sport.Purpose:To investigate clinical outcomes of ALLR and accelerated rehabilitation with a minimum duration of postoperative ankle immobilization and proactive early weightbearing.Study Design:Case series; Level of evidence, 4.Methods:This study investigated 23 ankles of 22 patients (11 men, 11 women; mean age, 38.7 years) who underwent ALLR for chronic lateral ankle instability. Postoperative management included the avoidance of weightbearing until postoperative day 3, after which full weightbearing walking with a brace was permitted. The objective was to return to competitive sport 8 weeks after surgery. The following were evaluated: pre- and postoperative instability and pain symptoms, ankle range of motion, anterior drawer distance on stress radiograph, anterior translation measured with a capacitance-type strain sensor, the Ankle-Hindfoot Scale from the Japanese Society for Surgery of the Foot, and the SAFE-Q (Self-Administered Foot Evaluation Questionnaire).Results:Two male patients dropped out and were excluded from analysis. Postoperatively, instability and pain resolved or improved in all patients. There was no significant postoperative change in range of motion. There were significant pre- to postoperative improvements in talar tilt angle (from 12.2°-5.6°, P < .01), anterior drawer distance (8.2-4.4 mm, P < .01), and anterior translation (10.5-4.6 mm, P < .01) as well as the Ankle-Hindfoot Scale score (68.8-96.8, P < .01) and all subscales of the SAFE-Q (P ≤ .01 for all). Complete return to sport was achieved by 75% of the patients at 8 weeks postoperatively.Conclusion:When accelerated rehabilitation with proactive weightbearing exercises was implemented from postoperative day 3 without ankle immobilization after ALLR, there were significant improvements in objective assessments of ankle stability and clinical scores, and as many as 75% of the patients were able to make a complete return to sport within 8 weeks.

A Comparison Between Functional Results in Intra-Articular Displaced Calcaneus Fractures Managed with Conservative and Operative Treatment: A Randomized Controlled Trial

Aim: To make a comparison between functional results in intra-articular displaced calcaneus fractures which are treated conservatively and operative treatment Study design: A randomized controlled trial Place and Duration:This study was conducted at ward 17 JPMC Karachi from January 20221 to January 2022. Methodology: This study includes 32 individuals who had displaced intra-articular calcaneal fractures. These individuals were classified into two groups, each group with 16 individuals. They were randomly assigned to either operative or conservative treatment. Clinical results, as well as radiological results (Modified Rowe’s score), were assessed at a 1-year follow-up. Results: All results were measured using Modified Rowe’s score. With a 1-year follow-up of the operative group, according to Modified Rowe’s score, 6 individuals had excellent results representing 37.5%, 8 individuals had good results representing 50%, and only 2 individuals had satisfactory results representing 12.5%. On the other hand, with a 1-year follow-up of the conservative group, only 2 individuals had excellent results representing 12.5%, 7 individuals had good results representing 43.75%, 5 individuals had satisfactory results representing 31.25%, and 2 individuals had poor results representing 12.5%. A few challenges were seen in each group. In the operative group, delayed wound healing was a complication seen in 2 cases while in the conservative group, peroneal tendonitis, subtalar arthritis and malunion were seen as a complication. Conclusion: In conclusion, the operative group was seen to be more effective to cure displaced intra-articular calcaneus fractures rather than the comparative group. Only a few complications, better functional recovery, early rehabilitation, and early weight bearing were seen in the operative treatment. Keywords: Calcaneus fractures, functional outcome, rehabilitation, conservative treatment

Two Orthogonal Nitinol Staples and Combined Nitinol Staple-Screw Constructs for a First Metatarsophalangeal Joint Arthrodesis: A Biomechanical Cadaver Study.

End-stage hallux metatarsophalangeal (MTP) joint arthritis is commonly treated with arthrodesis using stainless steel or titanium implants. These implants provide static compression that is maximal at the time of implant insertion. Alternatively, nitinol staples are capable of dynamic compression. They have most frequently been used for midfoot arthrodesis procedures. However, their biomechanical performance during hallux MTP arthrodesis has not been described. 8 matched pairs of cadaveric feet (4 female, 4 male) were prepared for hallux MTP arthrodesis using cup and cone reamers. Cadaveric pairs were then instrumented with either (1) a transarticular lag screw and dorsal nitinol staple or (2) orthogonal nitinol staples placed dorsally and medially. Walking in a short leg cast for 6 weeks was simulated by applying 90-N forces at 3 Hz to the plantar proximal phalanx for up to 250 000 cycles. Failure was defined as catastrophic implant failure or plantar gapping beyond 7 mm. 15 of 16 specimens failed cyclic loading. All 8 specimens fixed with orthogonal staples failed at an average of 37 ± 81 cycles. 7 of 8 specimens fixed with a dorsal staple and crossed screw failed at 14 900 ± 39 000 cycles. Collectively, 5 specimens failed because of bone fracture (1 in orthogonal staples, 4 in staple-screw group) and 10 failed because of excessive gap formation (7 in orthogonal staples, 3 in staple-screw group). The number of cycles to failure was significantly lower (P = .0469) in the orthogonal staple constructs compared with the dorsal staple and crossed screw constructs. The tested constructs permit significant motion at the first MTP fusion surface during simulated protected weightbearing. Although multiple in vivo factors should be considered when extrapolating results from this cadaveric study, this motion may result in clinical failure with early postoperative weightbearing protocols. We report the first biomechanical evaluation of hallux MTP arthrodesis using modern nitinol staples in 2 separate constructs.

Wide excision and reconstruction with free vascularized fibula for aggressive giant cell tumor of distal 3rd tibia

Giant cell tumor (GCT) at distal end of tibia is relatively a rare site of occurrence. We presented our experience with extensive excision and reconstruction for GCT of distal tibia using a free vascular double strut/single strut fibula graft. The present case series was conducted on six patients of GCT at lower end of tibia who were treated with extensive excision and reconstruction either in index (n=4) or recurrence (n=2) settings. Four patients were male and 2 were female. The mean age was 26.5 years. The average length of bone defect after tumor excision was 7.4 cm. The range of movement at ankle joint up to 70% of normal opposite side achieved in 2 cases and arthrodesis of ankle joint done in rest 4 cases (2 recurrent and 2 index cases). In GCT treatment, in spite of reconstruction difficulty for bony defect of lower end tibia due to its weight bearing property, vascularized free fibula graft has advantages like allows wide excision of tumor, single stage procedure, early weight bearing capacity in young patients and no bone resorption but bone thickening.

Study of outcome of surgical management of diaphyseal fractures of tibia treated with intramedullary interlock nailing

The overall incidence of diaphyseal fractures of tibia is 26/1,00,000 population. With the increasing number of vehicles on roads in India, complex trauma cases caused by road traffic accidents have increased progressively. The method of closed nailing with or without reaming followed by early ambulation and weight bearing has positive advantages over all existing methods, significant lower complication rates and has comparable results. The present study has been taken to review the results of diaphyseal fractures of tibia treated with intramedullary interlock nailing.

Weight-bearing Allowed Following Internal Fixation of Ankle Fractures, a Systematic Literature Review and Meta-Analysis.

Postoperative management regimes vary following open reduction and internal fixation of unstable ankle fractures. Traditional postoperative nonweightbearing cast immobilization may prevent loss of fixation and protect the soft tissue envelope but may also be associated with poorer functional outcomes. This systematic review and meta-analysis aimed to compare the complication rate and functional outcomes of early weightbearing (EWB) vs late weightbearing (LWB) following open reduction and internal fixation of ankle fractures. We performed a systematic review with a meta-analysis of controlled trials and comparative cohort studies using 3 databases. We included all studies that investigated the effect of weightbearing following internal fixation of ankle fractures in adult patients by any means. Studies that investigated mobilization but not weightbearing, non-English-language publications, and tibial Plafond fractures were excluded from this systematic review. We assessed the risk of bias using ROB 2 tools for randomized controlled trials and ROBINS-1 for cohort studies. Data extraction was performed using Covidence online software and meta-analysis by using RevMan 5.3. This systematic review included 10 randomized controlled trials and 4 comparative cohort studies. Most of the included studies were rated as having some concern with regard to the risk of bias. There was no significant difference in the complication rate between the protected EWB and LWB groups (the risk ratio [RR] for infection was 1.30, 95% CI 0.74, 2.30; I² = 0%; P = .36), but better functional outcome scores were detected in the EWB group only at 6 weeks postoperatively (MD =10.08, 95% CI 5.13, 15.02; I² = 0%; P ≤ .0001), with no significant difference seen at 6 or 12 months postoperatively. Based on the studies reviewed, it appears that early protected weightbearing following open reduction and internal fixation of ankle fractures does not affect surgical incision or fracture healing and is associated with better early functional outcomes at 6 weeks, but not 6 or 12 months, postoperatively.

Early weight-bearing constructs in the lower extremity

In early 2020, in the editorial “A call to arms: it's time to bear weight,” Trompeter[1] stated: “as we travel down the limb, we see an increased reluctance on the part of the treating surgeon to allow the patient to bear weight postoperatively.” While early weight-bearing in postoperative hip fracture constructs is well established, fractures distal to the hip are less likely to be allowed full mobilization, even in the frail elderly. A steadily increasing stream of literature, from the ankle up, shows potential advantages in immediate weight-bearing in the lower extremity with few, if any, ill effects.[2–5] While the literature itself is not always Level 1 or methodologically robust, surgeons must be aware of this option as they deal with an onslaught of fragility fractures in the lower extremity.[6] In the last 10 years of Orthopaedic Trauma Association material, early weight-bearing studies have been published, but the topic has never had its own focus in a supplement. We believe it is important for the Orthopaedic Trauma Association to give this subject focused traction, so that community and other surgeons feel comfortable initiating these changes after learning from the experiences of master surgeons who are early adopters and pioneers of new constructs and techniques in this arena. Early mobility and weight-bearing is extremely important for decreasing medical complications, morbidity, and mortality in our patients, particularly in the elderly. The aims of this supplement include a combination of thorough literature reviews, case series replete with examples of constructs such as the nail-plate for the distal femur, and technique tips to increase the comfort of the treating surgeon in allowing early weight-bearing. Special attention is paid to the distal femur, as a fragility fracture with similar morbidity as hip fractures, but the supplement also includes the proximal tibia/plateau, distal tibia, and ankle.

Factors associated with perioperative deep vein thrombosis in arthroscopic anterior cruciate ligament reconstruction

BackgroundAnterior cruciate ligament reconstruction (ACLR) is reportedly associated with a higher incidence of deep vein thrombosis (DVT) incidence than other arthroscopic surgical procedures. The aim of this study is to retrospectively investigate the incidence and type of DVT and evaluate the relationship between DVT and risk factors among all patients who underwent ACLR under uniform conditions consisting of mechanical prophylaxis, no medical prophylaxis, and preoperative and postoperative lower extremity venous ultrasonography. MethodsOf the 114 patients who underwent arthroscopic primary ACLR at our hospital who did not have a compound ligament injury or revision surgery, 112 patients were included. Two patients were not examined. DVT evaluation consisted of whole-leg ultrasonography at 1 week after surgery. We evaluated age, sex, body mass index, comorbidities, operative time, tourniquet time, presence of concurrent surgery (meniscus repair/resection or osteochondral column grafting), and non-weight-bearing status at 1 week after surgery as risk factors for DVT. ResultsDVT was found in 33 (29.5%) of 112 patients. Of these, 22 (19.6%) had distal DVT and 11 (9.8%) had proximal DVT. Non-weight-bearing status at 1 week after surgery was a statistically significant risk factor for proximal DVT (P = .034). ConclusionsNon-weight-bearing status is an independent risk factor for DVT, suggesting that early weight bearing may reduce the occurrence of DVT.

Does augmentation of intramedullary nails by a buttress plate effectively restore lateral wall integrity in intertrochanteric fractures.

Recent studies have proved the importance of intact lateral trochanteric wall, thus buttressing/fixing the broken lateral trochanteric wall irrespective of the implant, is likely to improve the alignment and outcome. We compared the outcome of lateral wall buttressing by trochanteric buttress plate (TBP) supplemented to proximal femoral nailing versus proximal femoral nailing alone in patients of broken lateral wall intertrochanteric fractures. Sixty patients of intertrochanteric factures (IT) of femur with broken lateral wall were randomized into group A or B and were treated with either proximal femoral nail (PFN) alone or proximal femoral nail augmented with trochanteric buttress plate (PFN + TBP), respectively. The TBP plate used was primarily fixed to proximal femur via 8mm hip screw and 6.4mm antirotation screw of the PFN. Operative time, blood loss, radiation exposure, quality of reduction, functional outcome, union time, and complications were compared. The mean age was 60.03 + 7.60 (range 42 to 70years), with male to female ratio of 4:1 and left to right ratio of approximately 1:1. The mean follow up in the series was 16.2months (range 13 to 36months). Mean duration of surgery, mean intra-operative blood loss, and mean number of exposures in group A (PFN alone) were 64.88 + 12.24min (48 to 88), 93 + 1.18ml (60 to 120), and 32.13 (24 to 46) and in group B (PFN with TBP plate) were 91.86 + 12.78min (70 to 122min), 144.8 + 3.6ml (116 to 208ml), and 56.6 (38 to 112), respectively. Twenty-five patients and 28 patients in groups A and B respectively achieved score of 4 Chang quality reduction. Mean union time was 13.4weeks in group A whereas in group B was 11.6weeks. Mean HHS score in group A was 87.86 with 90% patients in comparison to 94.13 and 97% cases having excellent to good results in group B. In group A, 24 patients, while 29 patients in group B, had excellent to good results. Four patients had hip pain, four had impingement of screws, two had screw migration, three had Z/reverse effect, and four patients had shortening of more than 1cm in group A. In group B, only one patient had impingement and none of the patient had hip pain, infection, implant failure, Z effect, or shortening. The lateral trochanteric wall in IT fractures is significantly important, and when the lateral wall is broken, it can lead to poor results. TBP plate which is applied laterally on femur along with nail and fixing the plate with hip screw and antirotational screw provides faster union, early weight bearing, better reduction, and so better hip functions. TBP can be used successfully to augment, fix, or buttress the lateral trochanteric wall giving excellent to good results but at the cost of surgical time, blood loss, and radiation exposure.

Functional and radiological outcome of primary fixation of compound tibial fractures with LRS and antibiotic beads: A prospective case series

Open fractures are more common in tibia than in any other long bones due to its distal location and less soft tissue envelope. The conventional goals for treatment of open tibial fractures include prevention of infection, soft tissue coverage, and fracture stabilization leading to union. LRS (limb reconstruction system) considered as a definitive treatment option, as it offers rigid fixation of fracture fragments and allows early weight bearing and reduces economic burden for patients. In this study, we are using antibiotic beads (as the local prophylactic device to prevent future infection) along with Limb Reconstruction System (LRS) to allow for the aseptic union of fracture while the patient is mobile throughout the period of treatment and without the requirement of another surgery.