Early Postoperative Weight Bearing Research Articles

Surgical Management of Complex Ankle Fractures in Patients with Diabetes: A National Retrospective Multicentre Study.

Objectives: Patients with ankle fractures associated with diabetes experience more complications following standard open reduction-internal fixation (ORIF) than those without diabetes. Augmented fixation strategies, namely extended ORIF and hindfoot nails (HFNs), may offer better results and early weightbearing in this group. The aim of this study was to define the population of patients with diabetes undergoing primary fixation for ankle fractures. Secondarily, we aimed to assess the utilisation of standard and augmented strategies and the effect of these choices on surgical outcomes, including early post-operative weightbearing and surgical complications. Methods: A national multicentre retrospective cohort study was conducted between January and June 2019 in 56 centres (10 major trauma centres and 46 trauma units) in the United Kingdom; 1360 patients with specifically defined complex ankle fractures were enrolled. The patients' demographics, fixation choices and surgical and functional outcomes were recorded. Statistical analysis was performed to compare high-risk patients with and without diabetes. Results: There were 316 patients in the diabetes cohort with a mean age of 63.9 yrs (vs. 49.3 yrs. in the non-diabetes cohort), and a greater frailty score > 4 (24% vs. 14% (non-diabetes cohort) (p < 0.03)); 7.5% had documented neuropathy. In the diabetes cohort, 79.7% underwent standard ORIF, 7.1% extended ORIF and 10.2% an HFN, compared to 87.7%, 3.0% and 10.3% in the non-diabetes cohort. Surgical wound complications after standard-ORIF were higher in the diabetes cohort (15.1% vs. 8.7%) (p < 0.02), but patients with diabetes who underwent augmented techniques showed little difference in surgical outcomes/complications compared to non-diabetes patients, even though early-weightbearing rates were greater than for standard-ORIF. Conclusions: Ankle fractures in diabetes occur in older, frailer patients, whilst lower-than-expected neuropathy rates suggest a need for improved assessment. Augmented surgical techniques may allow earlier weightbearing without increasing complications, in keeping with modern guidelines in ankle fracture management.

SURGICAL MANAGEMENT OF COMPLEX ANKLE FRACTURES IN PATIENTS WITH DIABETES: A NATIONAL RETROSPECTIVE MULTICENTRE STUDY

BackgroundAnkle fractures associated with diabetes experience more complications following standard Open-Reduction-Internal-Fixation (ORIF) than those without diabetes. Augmented fixation strategies namely extended ORIF and hind-foot-nail (HFN) may offer better results, and early weightbearing in this group. The aim of this study was to define the population of patients with diabetes undergoing primary fixation for ankle fractures. Secondarily, to assess the utilisation of standard and augmented strategies and the effect of these choices on surgical outcomes including early post-operative weight bearing and surgical complications.MethodsA national-multicentre retrospective cohort study was conducted between January to June 2019 in 56 centres (10 Major- Trauma-Centres and 46 Trauma-Units) in the United Kingdom; 1360 specifically defined complex ankle-fractures were enrolled. Demographics, fixation choice, surgical and functional outcomes were recorded. Statistical analysis was performed to compare high-risk patients with/without diabetes.ResultsThere were 316 patients in the diabetes cohort with mean age 63.9yrs (vs. 49.3yrs in non-diabetes cohort), and greater frailty score &gt;4 (24% vs.14% (non-diabetes cohort) (p&lt;0.03); 7.5% had documented neuropathy. In the diabetes cohort, 79.7% underwent standard ORIF, 7.1% extended ORIF and 10.2% a HFN compared to 87.7%, 3.0% and 10.3% in the non-diabetes cohort. Surgical wound complications after standard-ORIF were higher in the diabetes cohort (15.1% vs. 8.7%) (p&lt;0.02) but patients with diabetes who underwent augmented techniques showed little difference in surgical outcomes/complications to non-diabetes, even though early-weight- bearing rates were greater than standard-ORIF.ConclusionAnkle fractures in diabetes occur in older, frailer patients; whilst lower than expected neuropathy rates suggest a need for improved assessment. Augmented surgical techniques may allow earlier weight-bearing without increasing complications in keeping with modern guidelines in ankle fracture management.

Outcomes of Early Weightbearing Following Open Reduction and Internal Fixation in the Geriatric Population

Category: Ankle; Trauma Introduction/Purpose: Ankle fractures are the third most common extremity fracture, and its incidence is increasing in the elderly [1,2]. While the operative indications in ankle fractures have been established, there is no consensus regarding timing of weightbearing. There has been a growing trend towards early weightbearing due to its advantages in rehabilitation and return to function [3,4,5]. Even so, a survey study revealed that physicians tend to increase the non-weightbearing period for their geriatric population [6]. Expanding on our prior data which advocated for early weightbearing in ankle ORIF patients with syndesmotic injuries, we investigated the effects of early weightbearing after ankle ORIF in the geriatric population [7]. We hypothesized that there would not be an increased complication rate in this study cohort. Methods: A retrospective review was performed of patients over the age of 60 that underwent ankle ORIF at a level 1 trauma center and three neighboring community hospitals from 2015 to 2023. One of three senior surgeons were involved in all cases. Patient demographics, medical comorbidities, concomitant injuries, fixation method and complications were recorded. Maisonneuve injuries, fractures with articular surface involvement greater than 25%, open fractures, and revision cases were excluded. Patients with neuropathy were also excluded. All patients underwent an ORIF with possible syndesmotic fixation depending on intraoperative findings. Postoperatively, patients were 50% partial weightbearing for 2-3 weeks for a period of soft tissue and wound healing. After that, all patients were permitted to bear as much weight as tolerable. Results: 113 patients were identified that met our criteria. The average age was 72.6 years old. 25 were male and 88 were female. The average BMI was 26.8%. 60.2% of patients reported one or more medical comorbidities. The average follow-up time was seven months. We had zero major postoperative complications to report. We considered major complications to include: hardware failure, gross loss of reduction, need for revision ORIF, and accelerated post traumatic arthritis. Four patients were noted to have delayed wound healing. An additional four patients had minor surgical site infections that resolved with oral antibiotics. Six patients underwent hardware removal for various reasons. 65/113 (57%) patients received syndesmotic fixation of some form. Conclusion: This is the largest study to date reporting on effects of early weightbearing in the geriatric ankle ORIF population. In our study of 113 patients, all patients were allowed to weight bear as tolerated after short period of soft tissue rest, indiscriminate of syndesmotic injury or osteoporosis. We report no major complications and a limited number of soft tissues related complications. In a patient population with a known morbidity from prolonged immobility, as evidenced from the hip fracture literature, we hope our data helps to build confidence in early postoperative weightbearing [8].

Four-Leg Sustained Dynamic Compression Staple and Screw Generates Superior Lapidus Construct as Compared to Plate and Screw: A Biomechanical Study

Category: Ankle; Basic Sciences/Biologics Introduction/Purpose: Lapidus procedures are frequently used to treat moderate to severe hallux valgus in the setting of first tarsometatarsal instability or arthritis. The push for early weightbearing can lead to nonunion rates reaching 12%. A growing number of surgeons are utilizing orthopedic staples manufactured from NiTiNOL in foot and ankle arthrodesis procedures. These staples are inserted in an “open expanded” state which enables application of sustained dynamic compression (SDC) between bony segments, which can persist even when challenged with joint settling / bony resorption. The biomechanical performance of these devices has not been quantified in the setting of Lapidus procedures. This study determined the optimum SDC staple construct during Lapidus procedures, and to compare their performance to traditional plate and screw construct in an established model. Methods: Lapidus procedures were performed on synthetic bone replicates (Sawbones) using three SDC staple constructs and one static device construct: (1) dorsal four-leg inline SDC staple, (2) dorsal four-leg inline SDC staple with medial two-leg SDC staple (3) dorsal four-leg inline SDC staple with plantar medial-distal to lateral-proximal cannulated screw and (4) dorsomedial plate and distal dorsal to proximal plantar cannulated screw (FigA). Samples underwent four-point bending with calibrated servo- hydraulic machine (MTS). Max load and construct stiffness was calculated. Interfragmentary contact force, area, and pressure was measured with pressure sensor (Tekscan) and joint plantar gap measurements were completed with 3D motion capture system (Motion Analysis). Testing consisted of stepwise loading to 1, 2, and 3mm of crosshead displacement. For brevity, only data from 3mm displacement test are included herein. Data were analyzed with one-way ANOVA with Dunnett’s post hoc test (N=5/group). Results: The four-leg inline staple + two-leg staple and the four-leg inline staple + screw groups exhibited a 2.5x (p=0.03) and 7.5x (p &lt;.001) increase in joint contact force as compared to the plate + screw group, respectively (FigB). The four-leg inline staple + two-leg staple and the four-leg inline staple + screw groups demonstrated a 3.5x (p=0.002) and 6.6x (p &lt;.001) increase in joint contact area as compared to the plate + screw group, respectively (FigC). The four-leg inline staple + screw group exhibited a 65.1% reduction in plantar gap as compared to the plate + screw group (p=.039, FigD). Conclusion: The four-leg inline staple + screw group exhibited the optimal Lapidus construct biomechanical properties (greatest joint contact force, greatest joint contact area, and least plantar gap). The biomechanical testing performed herein was undertaken to simulate loading akin to early post-operative weight bearing. These data highlight the ability of the four-leg SDC NiTiNOL staple in combination with a static screw to provide meaningfully increased joint compression, uniformity of joint compression, and decreased construct motion as compared to the standard plate + screw construct that is frequently used clinically.

Biomechanical research of medial femoral circumflex vascularized bone-grafting in the treatment of early-to-mid osteonecrosis of the femoral head: a finite element analysis

PurposeHip preservation therapy of early ONFH (Osteonecrosis of the femoral head) has emerged as one of the hot areas of research. We have optimized the procedure of traditional MFCVBG (medial femoral circumflex vascularized bone grafting) by using specialized surgical tools and used the finite element analysis to guide the implantation position of the bone flap during surgery and validate the biological mechanical stability of the modified MFCVBG.MethodsThis study was based on the data of a male patient with left hip (ARCO stage IIB, JIC type C) hormonal ONFH. Harris score (HHS), anteroposterior and lateral hip radiographs, frog position hip radiographs and SPECT/CT of femoral head flow imaging were performed postoperatively to evaluate clinical efficacy. The patient’s CT data were used to establish upper femur finite element model of the normal group, osteonecrosis group and postoperative group, respectively. The force on the femoral structure of each group was analyzed under four different loads in the gait cycle of 0.5 times the body weight (0.5 G, standing on two feet), 2.75 G (standing on one foot), 4 G (walking with the middle foot on the ground) and 7 G (walking with the toe off the ground) to validate the biological mechanical stability of the modified MFCVBG, predict femoral head collapse risk, simulate of the different healing conditions of postoperative bone flap, and analyze the postoperative effect of non-ideal surgical model.ResultsAccording to the follow-up results, the bone flap and the inner wall of decompression channel healed well, no osteonecrosis progression, no local collapse or micro-fracture occurred in the femoral head, and the articular surface was intact and the necrosis was well repaired. According to the result of the finite element analysis, compared with the osteonecrosis group, the overall stress and displacement peak of the upper femur and the cortical bone stress peak of the femoral head in the postoperative group and normal group were significantly reducing; modified MFCVBG can significantly improve the biomechanical stability of necrotic femoral head and reduce the risk of femoral head collapse; there was no obvious abnormal stress distribution in the greater trochanter and intertrochanter region after the flap was removed; the bone flap of the complete removal of necrotic focus + long bone flap group was directly placed at the bottom of the decompression passage, and the bone flap cortical bone can provide substantial mechanical support; in theory, patients can try to reduce the load with crutches or walking aids and carry out appropriate flat activities to effectively promote the early postoperative recovery.ConclusionsThe modified MFCVBG resulted in good efficacy, safety and feasibility. The necrotic focus should be completely removed during the operation, and the long bone flap should be placed directly under the subchondral bone. For patients with better bone healing ability, a more positive attitude can be taken to promote early postoperative weight-bearing.

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 &amp; 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 &gt;4 (24% vs.14% (non-diabetes) (p&lt;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&lt;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.

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.

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.

Early weight bearing and mobilization decrease perioperative complications in patients after ankle fracture; the retrospective multicenter (TRON group) study

BackgroundOpen reduction and internal fixation (ORIF) for unstable ankle fractures (AF) are relatively predictable with excellent outcomes. Rehabilitation strategies are still being debated after surgical intervention for AF: non-weight bearing and cast immobilization for six weeks after the surgical repair of unstable AF or early functional treatment with partial weight bearing. This study aimed to compare early weight bearing and functional outcomes and complications. MethodsBetween April 2014 and March 2019, 1421 patients with AF underwent ORIF at 11 institutions (TRON group). The patients were divided into two groups: Group E started weight bearing within six weeks after surgery, and group L started weightbearing for more than six weeks after. To adjust for baseline difference between groups, a propensity score-matched algorithm was used to match Group E with Group L in a 1:1 ratio of 294 cases each. We compared the American Orthopedic Foot and Ankle Society (AOFAS) score as the functional outcome, the rate of wound dehiscence, superficial and deep infections, blistering, nonunion, neurapraxia, and reoperation at 3, 6, and 12 months after surgery. ResultsThe mean period of non-weight bearing was significantly shorter in group E (3.68 ± 1.02 vs. 6.67 ± 1.43; P < 0.001). The mean period of cast immobilization term were shorter in group E (1.84 ± 1.35 vs. 2.65 ± 1.51; P < 0.001). There were no differences in the AOFAS score at any period. The rates of deep infection and reoperation in Group E were significantly lower than those in Group L (1.7% vs. 6.1%; P = 0.009, 2.0% vs. 7.8%; P = 0.002, respectively). There were no significant differences in superficial infection (9 vs. 15; P = 0.297), nonunion (9 vs. 15 P = 0.30), blistering (4 vs. 3; P = 1.00), neurapraxia (2 vs. 1; P = 1.00), and wound dehiscence (15 vs. 18; P = 0.72). ConclusionsAlthough functional outcome was similar depending on whether early weight bearing was allowed, the rates of deep infection and reoperation decreased in patients with early weight bearing. We recommend early postoperative weight bearing in patients with a surgically treated AF.

Early Weight Bearing after Distal Femur Fracture Fixation

ObjectivesTo assess outcomes following early weight bearing after distal femur fracture fixation with locked lateral plating.DesignRetrospective cohort studySettingTwo Level 1 Academic Trauma Centers.Patients/ParticipantsPatients 18 years and older with distal femur fractures treated with locked lateral platingInterventionEarly full weight bearing (defined as less than 30 days from date of surgery) versus restricted post-operative weight bearingMain Outcome MeasurementsComposite complication comprising malunion, nonunion, surgical site infection, re-admission, or deathResults270 distal femur fractures were reviewed, with 165 meeting inclusion criteria. 21 patients had been allowed early full weight bearing. Fractures were divided into two groups based on when full weight bearing was allowed post-operatively. The two groups had similar fractures as determined by the distribution of AO distal femur fracture and Su periprosthetic femur fracture classifications. The early weight bearing group was significantly older and more comorbid. Despite being older, more comorbid, and allowed early full weight bearing on their fracture fixation construct, there was no difference in the rate of composite complications between groups.ConclusionOur data contributes to the small, but growing body of literature that has found no increased rate of fracture related complications in surgically treated distal femur fractures allowed early post-operative weight bearing.Level of EvidenceTherapeutic Level III Study.

Intertrochanteric fractures treated by diaphyseal support arthroplasty with hook plate vs cerclage wires only: A retrospective cohort study

BackgroundThe treatment of unstable fractures of the intertrochanteric region of the hip in the elderly is controversial. Conventionally, internal fixation with intramedullary nail or a dynamic hip screw is the treatment of choice in intertrochanteric fractures. Nowadays, some authors encouraged the use hip arthroplasty for management of these fractures with good outcome. The aim of this study is to compare total hip arthroplasty with hook plate against total hip arthroplasty with cerclage cables in the management of unstable intertrochanteric fractures. Materials and methodsOut of 100 admitted patients to a central university hospital in Beirut between 2013 and 2019 with a diagnosis of unstable intertrochanteric fracture of the hip, only 64 (36 hook plate vs 28 cerclage) patients were selected. This is a retrospective study, patients were excluded if lost to follow up, or if follow up less than one year is available. The data were retrieved from inpatient and outpatient hospital files. Functional outcomes were assessed according to ambulatory capacity. The main clinical measures were early postoperative full weight bearing, postoperative complications, functional outcome and radiologic assessment done by a radiologist in addition to measuring the dysfunction via the Harris Hip Score. ResultsThe time to full weight bearing, the rate of postoperative complications, radiologic outcome and the functional outcomes were more satisfactory in the hook - plate group than in the cerclage - cable group. ConclusionAccording to the results, total hip arthroplasty with hook plate is considered the preferred modality of treatment in mobile elderly patients above sixty-five years of age with an unstable intertrochanteric femoral fracture, despite being a bulky foreign material that can lead to trochanteric bursitis.

Slowed-Down Rehabilitation Following Percutaneous Repair of Achilles Tendon Rupture.

Background:Following percutaneous repair of acute Achilles tendon (AT) ruptures, early postoperative weightbearing is advocated; however, it is debatable how aggressive rehabilitation should be. We compared the clinical and functional outcomes in 2 groups of patients who followed either our “traditional” or a “slowed down” rehabilitation after percutaneous surgical repair.Methods:Sixty patients were prospectively recruited to a slowed down (29 patients) or a traditional (31 patients) rehabilitation program. Both groups were allowed immediate weightbearing postoperatively; a removable brace with 5 heel wedges was applied at 2 weeks. In the slowed-down group, 1 wedge was removed after 4 weeks. Gradual removal of the boot took place after 4 wedges were kept for 4 weeks. In the traditional group, 1 wedge was removed every 2 weeks, with removal of the boot after 2 wedges had been kept for 2 weeks. The AT Resting Angle (ATRA) evaluated tendon elongation. Patient reported functional outcomes were assessed using the AT Rupture Score (ATRS). Calf circumference difference and the isometric plantarflexion strength of the gastro-soleus complex were evaluated.Results:At the 12-month follow-up, both ATRA and ATRS were more favorable in the slowed-down group. The isometric strength and the calf circumference were more similar to the contralateral leg in the slowed-down group than in the traditional one.Conclusion:Following percutaneous repair of acute Achilles tendon patients undergoing slowed down rehabilitation performed better than the traditional one. These conclusions must be considered within the limitations of the present study.Level of Evidence:Level II, prospective comparative study.

Conventional vs Accelerated Rehabilitation Protocol Following Reattachment of Achilles Tendon for Insertional Achilles Tendinopathy.

No studies have compared early vs conventional postoperative weightbearing following suture bridge Achilles tendon reattachment. We, therefore, evaluated postoperative functional outcomes in these patients. We collected data on 49 patients who underwent surgical treatment of insertional Achilles tendinopathy using a central Achilles tendon-splitting approach and reattachment with suture bridge technique by a single surgeon. Functional outcomes were measured by a visual analog scale (VAS) for pain, Foot and Ankle Ability Measure (FAAM), and Short Form Health Survey (SF-36) at 3, 6, and 12 months postoperatively. The differences in outcomes were analyzed using multiple linear regression. Eighteen and 31 patients underwent the conventional and accelerated protocols, respectively; their corresponding mean ages were similar, 53 and 57 years, as were all other baseline characteristics. The mean scores (conventional vs accelerated group) for VAS for pain, FAAM, and SF-36 in the conventional group at 3 months postoperatively were 4 ± 1 vs 3 ± 1 points, 53 ± 8 vs 68 ± 3 points, and 57 ± 15 vs 67 ± 10 points (P < .05 for each comparison). There were no statistically significant differences between the groups at 6 and 12 months postoperatively. All patients could perform the single heel raise test at 6 months, and none experienced complications. In this small study, short-term functional outcomes were better in the accelerated group. More data are needed before the accelerated program can be recommended. Level II, prospective comparative study.

Postoperative Rehabilitation Following Achilles Tendon Repair: A Systematic Review.

The optimal postoperative management of Achilles tendon (AT) rupture remains unknown. The past 2 decades have witnessed a trend toward less rigid immobilization, earlier weightbearing, and accelerated functional rehabilitation postoperatively. The objective of this study was to identify all high-quality studies pertaining to rehabilitation after AT repair and characterize the various rehabilitation protocols that have been described. A systematic review of the English-language literature was performed according to PRISMA guidelines. All included studies represented level 1, 2, or 3 evidence and examined postoperative rehabilitation protocols following the repair of an acute AT rupture. A total of 1187 subjects were included. Surgical technique, rehabilitation protocol, and outcome assessment varied widely between studies. Early postoperative weightbearing with less rigid immobilization appears to accelerate short-term functional recovery. An aggressive rehabilitation program may also be advantageous in the short term, but further studies are needed to determine the long-term effects of these accelerated physical therapy and return-to-play protocols.

Biomechanics of periprosthetic femur fractures and early weightbearing.

The incidence of periprosthetic fractures is expected to rise increase by 4.6% every 10years between 2015 and 2060. There are few large series examining optimal fixation constructs or the influence of early ambulation on outcome. The purpose of this narrative review is to investigate the published biomechanical considerations for periprosthetic fracture fixation, with specific consideration of early postoperative weightbearing. A literature review was performed to identify fracture incidences, etiology, and current trends in weightbearing after fixation. Benefits of early weightbearing, current constructs, and biomechanics are reviewed. The limited data available support medical benefits and increased union rates with early mobilization. Optimal fixation constructs are not agreed upon, but mechanical studies suggest that dual implant constructs can support physiologic weightbearing loads. Further clinical trials are required to investigate fracture union and hardware complications in dual implant construct.

Interlocking Closed-Wedge High Tibial Osteotomy Modified With Oblique Osteotomy Lines and a Locking Plate Fixation

Closed-wedge high tibial osteotomy (CWHTO) is more advantageous over open-wedge high tibial osteotomy in the following viewpoints: (1) compression force from the patellar tendon to the osteotomy site contribute to its stability, (2) patellar baja less likely occurs, and (3) hardware implant is placed under the thick muscle, which could prevent risk of irritation and infection. Although conventional CWHTO resects the wedge bone, including the anterior and posterior cortices, interlocking CWHTO preserves them while performing osteotomy for the anterior or posterior cortex with only the proximal or distal osteotomy line, respectively. When the wedge is being closed, the distal fragment is internally rotated overlying the anterior and posterior cortices on the proximal and distal cortices, respectively. As a result, good rotational stability and anterior advancement of the tibial tubercle are obtained. Interlocking CWHTO can be applied for patients with moderate patellofemoral osteoarthritis. Adopting an oblique osteotomy line enables secure multiple screw fixations for a long locking plate with a good fitting, allowing early postoperative weightbearing.

Biomechanical Comparison of Fibertape Device Repair Techniques of Ligamentous Lisfranc Injury in a Cadaveric Model.

Lisfranc ligamentous injuries are complex, and their treatment, along with the preferred method of fixation, is controversial. Implementing a flexible synthetic augmentation device (fibertape) has been described as an alternative to traditional screw fixation. This biomechanical study evaluated two fibertape devices with interference screw fixation: InternalBrace, and InternalBrace with supplementary intercuneiform stabilization. The diastasis and relative angular displacement between bones were measured at three midfoot joints in the Lisfranc articulation. Measurements were obtained for the pre-injured, injured, and post-fixation stages under static loading. Specimens then underwent stepwise increases in cyclic loading performed at 1 Hz and 100 cycles, at 100 N ground reaction force intervals from 500 to 1200 N to simulate postoperative loading, and then up to 1800 N to simulate high loads. Failure of fixation was defined as diastasis greater than 2 millimeters at the second-metatarsal - medial-cuneiform joint. InternalBrace specimens demonstrated failures in 3 of 9 (33%) specimens at cyclic loads of 1000 N. Conversely, InternalBrace with Supplementary Limb specimens had 1 failure at 1200 N. The difference in diastasis at the second metatarsal-medial cuneiform joint was statistically significant between the two groups at higher loads of 1600N (p=0.019) and 1800N (p=0.029). The use of InternalBrace for ligamentous Lisfranc injuries appears to provide a biomechanically viable alternative for withstanding early postoperative protected weight bearing. Furthermore, the use of a supplementary limb in addition to the InternalBrace fibertape fixation method appears to enhance its biomechanical efficacy.

Combination of Cylindrical Autologous Bone Grafting Technique With a Metallic Block Insertion in Open-Wedge High Tibial Osteotomy

Open-wedge high tibial osteotomy (OW-HTO) is an effective surgical intervention for medial-compartment knee osteoarthritis. However, the osteotomized gap might be a disadvantage in OW-HTO because it can cause problems such as delayed bone union or loss of correction. These issues can be minimized by using autologous bone graft in the osteotomized gap, which is known to be the fastest and most clinically satisfactory gap filler. The primary mechanical stability of the osteotomy site in OW-HTO is essential for early weight bearing after surgery. Therefore, we introduce the combination of a cylindrical autologous bone grafting technique and a metallic block insertion for faster bone union and better primary stability of the site in OW-HTO. We expect that the described procedure will enable early postoperative weight bearing and, thereby, allow an early return to normal function.

Biomechanical Comparison of FiberTape Device Repair Techniques of Ligamentous Lisfranc Injury in Cadaveric Model

Category:Trauma; Basic Sciences/Biologics; Midfoot/Forefoot; SportsIntroduction/Purpose:Lisfranc ligamentous injuries are complex. Controversy exists regarding their treatment and preferred method of fixation. Fixation methods employing a FiberTape device and interference screw fixation have been described as an alternative to traditional screw fixation. The purpose of this biomechanical study was to evaluate two methods of fixation utilizing interference screw fixation with FiberTape augmentation in a cadaveric model.Methods:9 paired cadaveric feet (mid tibia/fibula) were separated into two groups based on fixation method: FiberTape alone and FiberTape with supplementary limb into the middle cuneiform via anchor. At three joints of the midfoot (second metatarsal - medial cuneiform, intermediate cuneiform - medial cuneiform, second metatarsal - intermediate cuneiform), the diastasis and relative angular displacement between bones in the coronal plane were measured for static and cyclic loading. Measurements were obtained for the native (pre-injured), injured, and post-fixation in static loading. Fixed specimens then underwent stepwise increases in cyclic loading performed at 1 Hz and 100 cycles, at 100 N intervals from 500 to 1800 N ground reaction force. The Achilles tendon was also loaded to simulate postoperative weightbearing. Failure of fixation was defined as diastasis at the second metatarsal - medial cuneiform joint greater than 2 millimeters.Results:FiberTape specimens demonstrated diastasis failures of 3 of 9 (33%) specimens at cyclic loads of 1000 N. Conversely, FiberTape with supplementary limb specimens all survived past this loading magnitude, with 1 failing at supraphysiologic loads (>1200 N). The difference in diastasis at the second metatarsal-medial cuneiform joint was statistically significant between the two groups at forces of 1600N (p = 0.019) and 1800N (p = 0.029). There were no significant differences between the other joint diastases and relative angular displacements.Conclusion:The use of FiberTape for fixation of ligamentous Lisfranc injuries appears to provide a biomechanically viable alternative for withstanding early post-operative protected weightbearing. Furthermore, the use of a supplementary limb in addition to the FiberTape fixation method appears to enhance its biomechanical efficacy under cyclic loading especially at higher loads.

Management of Lower Extremity Fractures in the Elderly: A Focus on Post-Operative Rehabilitation

Fractures in the elderly population are increasing in incidence and represent a rising burden of disease. It is difficult for the elderly population to adhere to restricted weight bearing, and immobility poses significant risks and increased morbidity. Therefore, a primary goal of fracture management in the elderly population is early post-operative weight bearing. This review examines published literature regarding lower extremity fracture management in the elderly, with a focus on post-operative rehabilitation. While extensive literature supports early weight bearing after hip fractures in the elderly, further research is warranted to provide guidelines for management of other lower extremity fractures in this population.