Early Postoperative Weight Research Articles

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 >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% 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<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.

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 <.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 <.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.

Epidemiology & management of complex ankle fractures in the United Kingdom: A multicentre cohort study

BackgroundPatient factors are known to contribute to decision making and treatment of ankle fractures. The presence of poor baseline mobility, diabetes, neuropathy, alcoholism, cognitive impairment, inflammatory arthritis or polytrauma can result in a higher risk of failure or complications. Limited evidence is available on the optimum management for this challenging cohort of patients herein described as complex ankle fractures. This UK multicentre study assessed and evaluated the epidemiology of ankle fractures complicated by significant comorbidity and patient factors and use of specialist surgical techniques such as hindfoot nails (HFN) / tibiotalarcalcaneal (TCC) nails and enhanced open reduction and internal fixation (ORIF). Patients and MethodsA UK-wide collaborative study was performed of adult distal AO43/AO44 fractures, associated with 1 or more of the patient factors listed above. Primary outcomes included patient demographics, comorbidities, surgical technique and implants. Secondary outcomes included surgical complications and early post-operative weight bearing instructions. Statistical analysis was performed to assess patient and fracture characteristics on outcome, including propensity matching. ResultsOne-thousand three hundred and sixty patients, with at least one of the above complex factors, from 56 centres were included with a mean age of 53.1 years. 90.2% (1227) patients underwent primary fixation which included 78.9% (1073) standard open reduction internal fixations (ORIF), 3.25% (43) extended ORIF and 8.1% (111) primary HFN / TCC. Overall wound complications and thromboembolic events were similar in the hindfoot nail group and the ORIF group (11.7% vs 10.7%). Wound complications were greater in diabetic patients versus non-diabetic patients independent of fixation method (15.8% vs 9.0%). After propensity matching for comorbidities and fracture type, overall complications were lower in the hindfoot nail (11.8%) and extended ORIF groups (16.7%), than the standard ORIF group (18.6%). ConclusionOnly a minority of complex ankle fractures are treated with specialised techniques (HFN/TCC or extended ORIF). Though more commonly used in older and frail patients their perceived advantages are often negated by a reluctance to bear weight early. These techniques demonstrated a better complication profile to standard ORIF but hindfoot nail with joint preparation for fusion was associated with more complications than hindfoot nail for fixation. Level of Evidence: III

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.

Early postoperative weight loss predicts nadir weight and weight regain after laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass.

Weight regain (WR) post bariatric surgery affects almost 20% of patients. It has been theorized that a complex interplay between physiologic adaptations and epigenetic mechanisms promotes WR in obesity, however, reliable predictors have not been identified. Our study examines the relationship between early postoperative weight loss (WL), nadir weight (NW), and WR following laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG). A retrospective review of prospectively collected data was conducted for LRYGB or LSG patients from 2012 to 2016. Demographics, preoperative BMI, procedure type, and postoperative weight at 6, 12, 24, 36, and 48 months were recorded. WR was defined as > 20% increase from NW. Univariate and multivariate linear and logistic regression models were used to determine the association between early postoperative WL with NW and WR at 4years. Thousand twenty-six adults were included (76.8% female, mean age 44.9 ± 11.9years, preoperative BMI 46.1 ± 8); 74.6% had LRYGB and 25.3% had LSG. Multivariable linear regression models showed that greater WL was associated with lower NW at 6months (Coef -2.16; 95% CI -2.51, -1.81), 1year (Coef -2.33; 95% CI -2.58, -2.08), 2years (Coef -2.04; 95% CI -2.25, -1.83), 3years (Coef -1.95; 95% CI -2.14, -1.76), and 4years (Coef -1.89; 95% CI -2.10, -1.68), p≤0.001. WR was independently associated with increased WL between 6months and 1year (Coef 1.59; 95% CI 1.05,2.14; p≤0.001) and at 1year (Coef 1.24; 95% CI 0.84,1.63;p≤0.001) postoperatively. The multivariable logistic regression model showed significantly increased risk of WR at 4years for patients with greater WL at 6months (OR 1.20, 95% CI 1.08,1.33; p = 0.001) and 1year (OR 1.14; 95% CI 1.06,1.23; p≤0.001). Our findings demonstrate that higher WL at 6 and 12months post bariatric surgery may be risk factors for WR at 4years. Surgeons may need to follow patients with high early weight loss more closely and provide additional treatment options to maximize their long-term success.

Early postoperative weight loss is associated with poor prognosis in patients with esophageal cancer.

Surgery for esophageal cancer (EC) causes morphological and functional changes in the upper gastrointestinal tract, resulting in postoperative weight loss (PWL). PWL has been shown to lead to poor nutritional status and immunocompetence, which may worsen the prognosis for several types of cancer. However, few reports have examined the relationship between weight loss (WL) in the early postoperative period and cancer prognosis. A total of 421 esophageal cancer patients underwent curative esophagectomy at Osaka University Hospital from 2010 to 2016. Based on the patients' body weight 1.5months after surgery, they were classified into severe WL (n = 50) and slight-moderate WL (n = 371) groups. The 5-year overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS) were significantly lower in the severe WL group than the slight-moderate WL group (p = 0.0002, p < 0.0001, and p = 0.0004, respectively). In the multivariate analysis, tumor invasion depth (pT3, 4), lymph node metastasis (pN2, 3), preoperative Prognostic Nutrition Index (< 45), postoperative complications (≥ G3), and severe WL were independent prognostic factors for CSS (hazard ratio [HR] 2.5, 95% confidence interval [CI] 1.7-3.7; HR 1.6, 95% CI 1.1-2.4; HR 1.9, 95% CI 1.3-2.8; HR 1.6, 95% CI 1.1-2.4; and HR 2.7, 95% CI 1.7-4.2, respectively). In a multivariate analysis of risk factors leading to severe WL, thoracotomy (VATS) and postoperative MAX CRP (high) were independent risk factors (odds ratio [OR 0.48, 95% CI 0.24-0.97; OR 1.9, 95% CI 1.0-3.5). Early PWL would be a useful marker of poor cancer prognosis in EC patients. Highly inflammatory conditions due to surgical invasion and postoperative complications may contribute to early PWL.

Early Postoperative Weight Loss Predicts Weight Loss up to 5 Years After Roux-En-Y Gastric Bypass, Banded Roux-En-Y Gastric Bypass, and Sleeve Gastrectomy

PurposePrevious studies showed that patients with lower weight loss after bariatric surgery could be identified based on early postoperative weight loss. However, these studies had only 12–36-month follow-up. This study aimed to explore whether patients in the lowest weight loss quartile at 3 months had lower weight loss trajectories up to 5 years after Roux-en-Y gastric bypass (RYGB), banded Roux-en-Y gastric bypass (BRYGB), and sleeve gastrectomy (SG) surgery.MethodsWeight was assessed preoperatively, and 3, 6, 9, 12, 24, 36, 48, and 60 months postoperatively. Patients were grouped into four categories based on quartiles of percentage total weight loss (%TWL) at 3-month follow-up. Results were compared between the lowest %TWL quartile group and other quartile groups.ResultsPatients underwent either RYGB (n=13,106; 72%), SG (n=3585; 20%), or BRYGB (n=1391, 8%) surgery. Weight loss trajectories of patients in the lowest %TWL quartile group remained lower than that of other quartile groups throughout a 5-year follow-up, for all three types of surgery. Patients in the lowest %TWL quartile group had higher age at surgery, higher baseline BMI, and were more likely to be male (in the SG group), and to suffer from diabetes, hypertension, dyslipidemia, and osteoarthritis.ConclusionThis study showed a positive association between weight loss at 3 and 12 to 60 months after bariatric surgery. Weight loss at 3 months after surgery could be used to identify patients whose anticipated weight loss trajectories are below average, to potentially improve their outcomes through early behavioral or medical interventions.Graphical

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.

S157-a structured early intervention program in patients with predicted poor long-term outcome following bariatric surgery: a prospective randomized study.

Early postoperative weight loss can be predictive of one-year outcomes. It is unclear if poor performers identified in the first post-operative month can have improvement in outcomes with additional support and education. To evaluate the impact of a structured targeted support program for patients with lower-than-average early post-operative weight loss on 1-year outcomes. This was a prospective randomized study of bariatric surgery patients who experienced less than 50th percentile excess body weight loss (%EWL) at 3 weeks. Subjects with EWL < 18% were randomized into two groups: an intervention (IV) arm or a control (NI, no intervention) arm. The IV arm was offered a program with 7-weekly behavioral support sessions, while the NI patients received routine post-operative care. A total of 128 patients were randomized: 65 NI and 63 IV. In the IV group, 20 attended all sessions, 7 attended < 4, and 36 did not participate. There was no difference in baseline demographics, procedure type, or BMI. At 1 year, there was no difference in %EWL (ratio 0.993, 95% CI 0.873, 1.131), %EBMIL (ratio 0.997, 95% CI 0.875, 1.137), and %TWL (ratio 1.016, 95% CI 0.901, 1.146) between groups. A subgroup analysis including only the subjects who participated in all seven sessions showed similar results. Patients who present with suboptimal weight loss early after bariatric surgery do not experience a significant weight loss improvement with a structured behavioral support program. Importantly, despite being alerted to their poor early weight loss, patients demonstrated poor adherence to the proposed interventions.

Predictive Factors of Cholelithiasis After Prophylactic Administration of Ursodeoxycholic Acid Following Laparoscopic Bariatric Surgery: Tehran Obesity Treatment Study.

Cholelithiasis is a well-known consequence of obesity as well as rapid weight loss especially after bariatric surgery. A routine postoperative course of ursodeoxycholic acid (UDCA) is recommended as a prophylactic measure against gallstone formation. However, the efficacy of UDCA after bariatric surgery and predictors of cholelithiasis despite prophylaxis are not well understood. We assessed the incidence and predictors of de novo cholelithiasis after bariatric surgery in patients who received UDCA prophylaxis. Uniform data from 2629 consecutive patients who underwent either sleeve gastrectomy or gastric bypass between March 2013 and 2018 were collected prospectively. All patients received a 6-month course of UDCA 300mg twice daily. Cholelithiasis was assessed with abdominal ultrasound at baseline as well as 6, 9, 12, 18, and 24months postoperatively. The association between cholelithiasis and its predictors was examined by Cox proportional hazards models and restricted cubic spline regression. The cumulative rate of cholelithiasis in 24months after surgery was 10.8% (n = 283) with the greatest incidence within the first year. After multivariate analysis, 6-month body mass index (BMI) loss was found to be the only independent predictor for postoperative cholelithiasis (HR = 1.10 [95% CI: 1.04-1.16]). The concordance index for predicting cholelithiasis was 0.60 (0.56-0.64) for 6-month BMI loss. Early postoperative rapid weight loss as represented by 6-month BMI loss is the main predictor of de novo cholelithiasis after bariatric surgery, although this parameter does not have enough power for discrimination of postoperative cholelithiasis.

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.

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.

Is early full weight bearing safe following locking plate ORIF of distal fibula fractures?

BackgroundIn the modern western world appraisal of economical points such as treatment and disability after trauma present a financial burden. In this context open reduction internal fixation techniques allowing for early full weight bearing might not only improve the clinical outcome but also shorten the period of disability in working life. The aim of the study was to analyze whether ORIF of ankle fractures using either a standard semitubular plate or a new polyaxial locking plate system result in a better clinical outcome.MethodsIn this prospective study, all patients with distal fibula fractures (AO 44 B1.1, B1.2, B1.3), with indication for surgery were included. Patients were randomized to either the DePuy Synthes® one-third semitubular plate (Group I) or NEWCLIP TECHNICS, Active Ankle® polyaxial locking plate (Group II). Primary outcome parameter was function of the ankle joint, assessed by the Olerud and Molander ankle score, Foot and Ankle outcome score and Karlsson and Peterson Scoring System for Ankle function. Secondary outcome parameter were postoperative complications. Superficial wound infection, delayed wound healing, mechanically prominent implant, skin irritations were considered as minor and deep wound infection, material loosening, loss of reduction were regarded as major complications requiring revision surgery. Clinical and radiological follow-up were performed 6 and 12 weeks, 6 months and 1 year postoperatively.ResultsFifty-two patients (31 W/21 M) with a mean age of 43 yrs. (range 22–64 yrs.) were enrolled. Seven patients (13.5%) were excluded, so that 45 patients were available for follow up. Twenty-five patients were treated with DePuy Synthes® one-third semitubular plate (55.6%; group I) while 20 patients received an anatomically preformed polyaxial locking plate (44.4%, group II). Four minor complications occurred in Group I (16%) compared to two minor complications in group II (10%). Significant better clinical results regarding OMAS (p < 0.02, < 0.04), KPSS (p < 0.04) and FAOS (p < 0.02, < 0.03) were observed 6 and 12 weeks after surgery in group II.ConclusionsThe results of the presented study demonstrate a significant better clinical functional outcome in the early postoperative follow-up in patients treated with a polyaxial locking plate. Furthermore, our data show that ORIF using polyaxial locking plates in combination with an early postoperative weight bearing presents a safe, stable treatment option for ankle fractures so that patients benefit especially in the early stages of recovery.Trial registrationRegistered 20 April 2020, retrospectively on ClinicalTrails.gov (NCT04370561).

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.

Baseline Presence of NAFLD Predicts Weight Loss after Gastric Bypass Surgery for Morbid Obesity.

Background. Bariatric surgery is a widely used treatment for morbid obesity. Prediction of postoperative weight loss currently relies on prediction models, which mostly overestimate patients’ weight loss. Data about the influence of Non-alcoholic fatty liver disease (NAFLD) on early postoperative weight loss are scarce. Methods. This prospective, single-center cohort study included 143 patients receiving laparoscopic gastric bypass surgery (One Anastomosis-Mini Gastric Bypass (OAGB-MGB) or Roux-en-Y Gastric Bypass (RYGB)). Liver biopsies were acquired at surgery. NAFLD activity score (NAS) assigned patients to “No NAFLD”, “NAFL” or “NASH”. Follow up data were collected at 3, 6 and 12 months. Results. In total, 49.7% of patients had NASH, while 41.3% had NAFL. Compared with the No NAFLD group, NAFL and NASH showed higher body-mass-index (BMI) at follow-up (6 months: 31.0 kg/m2 vs. 36.8 kg/m2 and 36.1 kg/m2, 12 months: 27.0 kg/m2 vs. 34.4 and 32.8 kg/m2) and lower percentage of total body weight loss (%TBWL): (6 months: 27.1% vs. 23.3% and 24.4%; 12 months: 38.5% vs. 30.1 and 32.6%). Linear regression of NAS points significantly predicts percentage of excessive weight loss (%EWL) after 6 months (Cologne-weight-loss-prediction-score). Conclusions. Histopathological presence of NAFLD might lead to inferior postoperative weight reduction after gastric bypass surgery. The mechanisms underlying this observation should be further studied.

The Effect of Family Member Attendance at Bariatric Surgery Appointments on Patient and Family Weight-Related Outcomes.

To assess the effect of family member attendance at routine pre- and postoperative appointments on early postoperative patients' weight loss and physical activity levels and family members' weight control practices. As part of a RCT, patients were randomized to (1) invite a romantic partner or cohabitating family member to attend routine appointments (FA arm) or (2) proceed with treatment as usual (TAU arm). Patients in FA arm were asked to invite their family member to attend four routine appointments (T1 = pre-surgery class, T2 = 1month pre-surgery, T3 = 2weeks post-surgery, T4 = 2months post-surgery). Assessments of patients' percent excess weight loss (%EWL), change in body mass index (ΔBMI), and levels of physical activity and family members' weight control practices (dietary control, self-monitoring, physical activity, and psychological coping) were conducted at T1-T4 with all dyads, and attendance was documented. Of the 213 dyads approached, 63 dyads consented to participate. There were no significant differences in patient outcomes between FA and TAU arms or based on consistent attendance of family members. There were no significant differences in weight control practices between FA and TAU dyads. At T3 and T4, family members with consistent attendance reported higher self-monitoring, physical activity, and psychological control practices. Family members with consistent attendance reported significant increases in physical activity and psychological control practices from T1 to T4. Family member attendance at routine appointments had greater positive effects on family members rather than on patient outcomes.

Short-Term Complications Following Early Protected Weight Bearing after Flatfoot Reconstruction when Utilizing a Fibertape Device for Spring Ligament Reefing Augmentation

Category:AnkleIntroduction/Purpose:In an estimated 70% of cases of Adult Acquired Flatfoot Deformity (AAFD) reconstruction, the spring ligament is elongated and/or damaged. Spring ligament reefing can be performed through several techniques including augmentation with Fibertape devices. In addition, biomechanical studies have demonstrated its safety and suggest early weight bearing may be performed. The purpose of this study is to evaluate the outcomes of early weight bearing following flatfoot reconstruction with use of InternalBrace augmentation for spring ligament reefing when performed in combination with medical displacing calcaneal osteotomy (MCO) and FDL tendon transfer.Methods:From 2016-2018, 45 patients underwent flatfoot reconstruction (MCO, FDL transfer, and gastrocnemius recession) with spring ligament reefing and augmentation with the InternalBrace device. All surgeries were performed by the senior orthopaedic surgeons (PJJ & MCA). Institutional early post-operative weight bearing protocol involves weight bearing as tolerated in a splint with crutches for two weeks, transitioning at 2 weeks to a Cam boot with 1 wedge WBAT. At 4 weeks, the patient is weaned off crutches and recommended to start therapy restricting excessive eversion and concentrating on calf strengthening, gait, and ROM. At weeks 6-8 they are weaned from the Cam boot into lace up ASO and shoe with arch support. Data were recorded at 2 weeks, 6 weeks, 12 weeks, 6 months and at yearly intervals. Outcomes and complications were documented.Results:Of the 45 cases there were no complications related to early weight bearing. Radiographic bony union rate of the MCO was 100% (45/45). Moreover, there was no loss of fixation of either the FDL transfer or spring ligament reefing with InternalBrace augmentation with early weight bearing. Lastly, radiographic evaluation noted no loss of Meary’s talo-first metatarsal angle when comparing initial postoperative radiographic to their final follow up. Additional complications in our cohort included the following: removal of painful hardware (1, 2.22%), sural neuritis (2, 4.44%), superficial cellulitis (1, 4.44%), and delayed lateral wound healing(1, 2.22%).Conclusion:Preliminary data shows that early protected weight bearing after flatfoot reconstruction and augmentation of the spring ligament with the InternalBrace device is safe and demonstrates few complications and no early loss of correction.

Early Post-operative Weight Change After Roux-en-Y Gastric Bypass Predicts Weight Loss at 12-Month Follow-up.

Sub-optimal weight loss following Roux-en-Y gastric bypass (RYGB) represents an important clinical challenge in a significant number of patients. Early identification of such patients would be advantageous, as it could aid in the selective implementation of targeted adjunct interventions during the first post-operative year. Clinical audit data from 1137 patients undergoing RYGB between 2013 and 2016 at the Instituto Sallet in Brazil were prospectively registered in an online database (BOLD) and analyzed. Forty-eight percent of patients achieving less than 5% total weight loss after the first post-operative month achieved a 20% total weight loss at 1year (n = 626; OR = 0.6 CI = 95%). Eighty-three percent of patients losing between 5 and 10% at 1month and 95% of patients losing greater than 10% at 1month had lost at least 20% of total body weight after the first post-operative year. Forty-four percent of patients achieving less than 10% total weight loss after the third post-operative month achieved 20% total weight loss at 1year (n = 494; OR = 0.3 CI = 95%). Total bodyweight reduction after RYGB of < 5% at 1month and < 10% at 3months is associated with suboptimal weight loss at 1year. These results reinforce findings from other studies reporting that patients tend to follow a common weight loss trajectory. Identifying the patients with weight trajectory requiring adjunct therapies early on is crucial so appropriate adjustments can be made to post-operative care.

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.