Lower Extremity Measures Research Articles

Morel-Lavallee associated lymphedema treated with lymphovenous anastomosis: A case report

Morel-Lavallee Lesions lead to disruption of lymphatic anatomy that require early identification and may necessitate lymphatic reconstruction. We present the case of a 59-year-old male with lower extremity lymphedema resulting after a severe Morel-Lavallee lesion and treated using lymphovenous anastomoses. He was initially managed with multiple aspirations followed by repeat incision and drainage. At 10 months following his injury, he continued to have swelling of his upper thigh and developed a large festoon medially, with lower leg pitting edema. He was diagnosed with lymphedema via lymphoscintigraphy. His superficial lymphatic anatomy was visualized using indocyanine green (ICG) lymphography and showed diffuse dermal backflow across his thigh, with signs of altered lymphatic anatomy distally. We preformed two lymphovenous anastomoses at the level of his mid-thigh to bypass the lymphatic disruption and restore drainage to his lower leg. After rerouting lymphatic flow from the lower extremity, the patient had overall improvement of his symptoms and reduced swelling with continued therapy. At 5 months postoperatively, his volumetric lower extremity measurements showed a decrease by 314 mL and he began walking again in 20-minute intervals. Lymphedema may be an important consideration following severe Morel-Lavallee lesions. Using modern diagnostic and supermicrosurgical techniques, plastic surgeons can help treat this long-term morbidity.

Clinical Measures of Adolescent Softball Players With and Without Upper-Extremity Pain: A Preliminary Study.

Upper-extremity (UE) pain is a concern among softball adolescent athletes. However, research on preseason screening of demographic characteristics and clinical measures among those with and without UE pain among adolescent softball athletes is underreported. This study sought to present functional outcomes and clinical measures of shoulder and hip complex flexibility, range of motion (ROM), and strength in adolescent softball athletes with and without UE pain. Cross-sectional study. Sixty-seven athletes were assessed at the start of the spring season. The Kerlan-Jobe Orthopedic Clinic Shoulder and Elbow Questionnaire was administered to determine UE function. UE measurements included shoulder ROM, flexibility, and strength; lower-extremity measurements included hip ROM and strength. These variables were reported for players with and without UE pain as mean and SD. Independent samples t tests were performed to analyze differences between the groups. Thirteen (19.4%) athletes reported UE pain during preseason screening. Mean Kerlan-Jobe Orthopedic Clinic Shoulder and Elbow Questionnaire score among athletes with UE pain was 58.0 (17.6) compared with 97.1 (6.9) for athletes reporting no UE pain (P < .001). Athletes with UE pain presented with significantly less dominant side external rotation ROM (UE pain: 106.5 [10.4], no UE pain: 114.6 [11.3]) and total ROM (UE pain: 163.7 [14.5], no UE Pain: 174.8 [14.3]). These findings inform clinicians on function and preseason clinical measures in adolescent softball athletes who present with or without UE pain. Athletes with UE pain demonstrated lower outcome scores indicating likely impact on overall UE function. These athletes also appeared to demonstrate UE ROM differences compared with athletes without UE pain. Further research is needed to investigate larger sample sizes and positional differences at baseline and throughout the season to determine if clinical measures used in the current study are risk factors for pain and injury.

An Analysis of the Increased Risk for Lower Extremity Injury Within 12 Months After Concussion and Utilization of Lower Extremity Measures for Return to Sport

Background:According to the Concussion Clinical Practice Guidelines, the typical recovery timeline post-concussion is about 7-14 days. However, recent research has shown an increased risk for lower extremity (LE) injury as early as 90 days and up to 1 year post-concussion.Purpose:The primary purpose of this study was to determine the prevalence of youth athletes who sustained a LE injury within 1 year post-concussion at Texas Children’s Hospital. The secondary purpose of this study was to describe the prevalence and utilization of LE functional testing performed by Physicians (MDs), Physical Therapists (PTs), and Athletic Trainers (ATs) as part of return to sport (RTS) clearance post-concussion.Methods:A retrospective chart review was completed consisting of patients diagnosed with a concussion by a Sports Medicine Physician from September 2018 to September 2020. The inclusion criteria were as follows: male or female, ages 8-21, and active participation in 1 or more sports. The data was collected in Microsoft Forms. Additionally, a Microsoft Forms survey was sent to Sports Medicine MDs, PTs, and ATs to assess utilization of LE functional tests. SPSS 25.0 was used for analysis with alpha level at .05. A one-sample chi-square test was utilized to compare re-injury rate to the known rate of 1%. Other proportional comparisons were run using two-sample chi-square analyses.Results:A total of 635 charts were reviewed with 527 patients participating in at least 1 sport. 12.7% (N=54) of those who sustained a concussion had either a musculoskeletal injury or another concussion within 1 year, with the highest proportion of injuries being a second concussion (33.3%) or ligament sprain (35.2%). Of the providers polled, 52.8% do not currently use a LE functional measure as part of RTS criteria. The most commonly reported reasons that providers do not use LE measures were as follows: not included in their standard of practice, lack of time, and lack of knowledge.Conclusion:The results suggest a LE test battery may be beneficial to assess LE injury risk post-concussion. Additionally, the majority of providers do not currently use LE functional measures when assessing RTS criteria. Considering the increased risk for LE injury and lack of LE functional testing completed by providers, further education about current, available LE functional testing should be provided to decrease the prevalence of LE injury after concussion. Future studies should analyze the effects of LE strengthening and functional testing on subsequent LE injury risk post-concussion.

Association Between Body Composition and Vertical Jump Performance in Female Collegiate Volleyball Athletes

Background of Study: Associations between measures of body composition and vertical jump height have previously been established using a range of instrumentation and prediction equations. Limited data has presented using gold standard measurements for both variables Objective: This investigation sought to examination the relationship between total body and lower extremity measures of body composition and vertical jump performance using gold standard measurements within an athletic population. Methods: Using a cross-sectional, correlational research design fourteen collegiate female volleyball athletes completed body composition, three countermovement jumps (CMJ) and three squat jumps (SJ) analysis using DXA and force platforms. Results: High to very high positive relationships were seen between total body lean (p &lt; 0.001) and fat mass (p &lt; 0.05), lower extremity lean and fat mass (p &lt; 0.01), and CMJ force and power. High negative relationships were present between total body fat percentage(p &lt; 0.05), total fat mass (p &lt; 0.01) and CMJ jump height. Relationships between all body composition variables and SJ performance tended to be weaker, with the exception of total body lean mass (p &lt; 0.05), lower extremity lean mass, and power output (p &lt; 0.01). Conclusions: These findings support much of the previous literature in that increases of mass have subsequent increases in force and power production; however caution should be taken will increases in mass coming from fat or lean tissue.

Shear wave elastography assessment and comparison study of the Achilles tendons in optimally conditioned asymptomatic young collegiate athletes.

To assess the functional parameters of the Achilles tendons among asymptomatic college level athletes using shear wave elastography (SWE) and to describe the relationship to athlete demographics and anthropometric lower extremity measurements. Sixty-five athletes were included in this IRB-approved study. SWE measurements were made on two tendon positions (neutral state and active maximum dorsiflexion) with two different probe orientations (longitudinal and transverse). Associations were assessed with BMI, tibial/foot length, type of sports, and resting/maximal dorsiflexion-plantar flexion angles. Thirty-five (53.8%) males and 30 (46.2%) females with an overall mean age of 20.9years (± 2.8), mean height of 176 cm (± 0.11), and mean weight of 74.1 kg (± 12) were studied. In the neutral state, the mean wave velocity of 7.5m sec-1 and the mean elastic modulus of 176.8kPa were recorded. In active maximum dorsiflexion, the mean velocity was 8.3m sec-1 and mean elastic modulus was 199kPa. On the transverse view, the mean velocity and elastic measurements were significantly lower (p = 0.0001). No significant differences in SWE parameters were seen between male and female athletes regardless of probe orientation (p < 0.05) with SWE values being higher in the running group vs non-running group (p < 0.05). In neutral state, longitudinal SWE measurements correlated with the tibia-foot length whereas transverse measurements correlated with the tendon diameter and ankle resting angle (ARA) (p < 0.005). SWE can distinguish functional differences in Achilles tendon stiffness between athletes engaged in running-intensive sports compared with other athletes.

Medial tibial stress syndrome: The relationship between gender and lower-extremity functional performance among collegiate track and field athletes

Medial tibial stress syndrome (MTSS) is a common lower extremity injury in track and field athletes. Many risk factors are associated with MTSS, and lower extremity performance may become altered in athletes suffering from prior symptoms, potentially increasing risk of future injury. The purpose of this study was to first examine the effect a prior history of MTSS has on lower-extremity measures, per gender, in collegiate level track and field athletes, and then determine if such measures predict future injury. Fifty-three healthy Division III collegiate track and field athletes (mean age = 19.40 ± 1.13 years) completed an injury history questionnaire along with five preseason lower-extremity functional tests including: ankle dorsiflexion (DF), single-leg anterior reach (SLAR), two timed single-leg balance (SLBAL) tests on a force plate, and single-leg hop for distance (SLH). Performance data were compared across gender and questionnaire data regarding injury history and occurrence of MTSS. Fifteen subjects (28%) reported previous MTSS symptoms within the last 2 years. Chi-square analyses revealed females experienced more diagnoses compared to males (p = .03). Independent t-tests revealed differences between gender on all SLBAL tests, as males performed better on all recorded measures (p &lt; .001 – p = .003). No significant differences were noted in lower-extremity performance tests between subjects with and without prior MTSS injuries. Regression analyses using postseason injury questionnaire data revealed prior MTSS injuries had 17.3 higher odds of experiencing MTSS during the season (adjusted odds ratio [AOR] = 17.33, 95% CI: 3.5 – 86.4; p = .001).

Reliability of EOS compared to conventional radiographs for evaluation of lower extremity deformity in adult patients.

The purpose of this study was to compare reliability of lower extremity imaging measurements using EOS and conventional X-ray (CR) of adult patients with mechanical axis malalignment. Ten patients (20 lower limbs) of mean age of 31.6years (range 21-39) with post-traumatic deformities who presented for evaluation of osteotomies and/or ligament and cartilage reconstructions were prospectively enrolled. Two independent observers performed full-length anterior-posterior (AP) measurements 2weeks apart on both CXR and two-dimensional (2D) EOS images. Measurements included weight-bearing axis (WBA), varus/valgus angle (V/V), femoral length (FL), tibial length (TL), femoral mechanical axis (FMA), tibial mechanical axis (TMA), and total limb length (TLL). Reliability was determined with random effects modeling of intraclass correlation coefficients (ICC) set to consistency. Three statistical operations were performed to compare interrater validity in CXR and EOS: students' two-sample t test, paired two-sample t test, and Pearson's correlative r-statistical agreement. There was a statistically significant difference for V/V, FL, and TLL (all p< 0.01) between CXR and EOS. A relatively large proportion of the population consistently had larger V/V measures for EOS compared to CXR. In contrast, the FL and TLL measures were consistently larger for CXR compared to EOS. The differences between CXR and EOS measurements were statistically significant, though the small differences in values were not clinically meaningful. Agreement of all measures remained high (r= 0.84-0.99). Using 2D EOS for lower extremity measurements is reproducible, reliable, and comparable to the gold standard, standing long leg radiographs.

The Pediatric Toronto Extremity Salvage Score (pTESS): Validation of a Self-reported Functional Outcomes Tool for Children with Extremity Tumors.

The physical function of children with sarcoma after surgery has not been studied explicitly. This paucity of research is partly because of the lack of a sufficiently sensitive pediatric functional measure. The goal of this study was to establish and validate a standardized measure of physical function in pediatric patients with extremity tumors. (1) What is the best format and content for new upper- and lower-extremity measures of physical function in the pediatric population? (2) Do the new measures exhibit floor and/or ceiling effects, internal consistency, and test-retest reliability? (3) Are the new measures valid? In Phase 1, interviews with 17 consecutive children and adolescents with bone tumors were conducted to modify the format and content of draft versions of the pediatric Toronto Extremity Salvage Score (pTESS). In Phase 2, the pTESS was formally translated into French. In Phase 3, 122 participants between 7 and 17.9 years old with malignant or benign-aggressive bone tumors completed the limb-specific measure on two occasions. Older adolescents also completed the adult TESS. Floor and ceiling effects, internal consistency, test-retest reliability, and validity were evaluated. Feedback from interviews resulted in the removal, addition, and modification of draft items, and the pTESS-Leg and pTESS-Arm questionnaires were finalized. Both versions exhibited no floor or ceiling effects and high internal consistency (α > 0.92). The test-retest reliability was excellent for the pTESS-Leg (intraclass correlation coefficient [ICC] = 0.94; 95% CI, 0.90-0.97) and good for the pTESS-Arm (ICC = 0.86; 95% CI, 0.61-0.96). Known-group validity (ability to discriminate between groups) was demonstrated by lower mean pTESS-Leg scores for participants using gait aids or braces (mean = 68; SD = 21) than for those who did not (mean = 87; SD = 11; p < 0.001). There was no significant difference between pTESS arm scores among respondents using a brace (n = 5; mean = 73; SD = 11) and those without (n = 22; mean = 83; SD = 19; p = 0.13). To evaluate construct validity, we tested a priori hypotheses. The duration since chemotherapy correlated moderately with higher pTESS-Leg scores (r = 0.4; p < 0.001) but not with pTESS-Arm scores (r = 0.1; p = 0.80), and the duration since tumor resection correlated moderately with higher pTESS-Leg scores (r = 0.4; p < 0.001) but not pTESS-Arm scores (r = 0.2; p = 0.4). Higher VAS scores (that is, it was harder to do things) antecorrelated with both pTESS versions (pTESS-Leg: r = -0.7; p < 0.001; pTESS-Arm: r = -0.8; p < 0.001). To assess criterion validity, we compared the pTESS with the current "gold standard" (adult TESS). Among adolescents, strong correlations were observed between the TESS and pTESS-Leg (r = 0.97, p < 0.001) and pTESS-Arm (r = 0.9, p = 0.007). Both pTESS versions exhibited no floor or ceiling effects and had high internal consistency. The pTESS-Leg demonstrated excellent reliability and validity, and the pTESS-Arm demonstrated good reliability and reasonable validity. The pTESS is recommended for cross-sectional evaluation of self-reported physical function in pediatric patients with bone tumors. Level II, outcome measurement development.

Altered vascular function in chronic kidney disease: evidence from passive leg movement.

Chronic kidney disease (CKD) is an independent risk factor for the development of cardiovascular disease and is characterized by reduced nitric oxide (NO) bioavailability and vascular dysfunction, typically assessed using brachial artery flow‐mediated dilation (FMD). It has been previously reported that passive leg movement (PLM)‐induced hyperemia, an assessment of lower extremity vascular function, is highly dependent on NO, but has not yet been utilized to assess vascular function in patients with CKD. The purpose of this study was to comprehensively assess vascular function in patients with CKD using PLM, in addition to the traditional FMD technique. Assessment of vascular function via PLM and FMD was performed on 12 patients (CKD, 66 ± 3 years) and 16 age‐matched healthy controls (CON, 60 ± 2 years). Blood velocity and artery diameters during PLM and FMD were measured using duplex ultrasound of the femoral and brachial arteries, respectively. Habitual physical activity, assessed by accelerometry, was performed in a subset of each group. CKD patients had reduced peak leg blood flow (LBF) (384 ± 39 vs. 569 ± 77 mL/min, P < 0.05) and change in LBF from baseline to peak (∆peakLBF) (143 ± 22 vs. 249 ± 34 mL/min, P < 0.05) during PLM compared to CON. Additionally, PLM responses were significantly associated with kidney function and physical activity levels. As anticipated, FMD was significantly attenuated in CKD patients (5.2 ± 1.1 vs. 8.8 ± 1.2%, P < 0.05). In conclusion, both upper and lower extremity measures of vascular function indicate impairment in CKD patients when compared to controls. PLM appears to be a novel and feasible approach to assessing lower extremity vascular function in CKD.

Comparing the Convergent and Concurrent Validity of the Dynamic Gait Index with the Berg Balance Scale in People with Multiple Sclerosis.

Background: Recent clinical guidelines for adults with neurological disabilities suggest the need to assess measures of static and dynamic balance using the Berg Balance Scale (BBS) and Dynamic Gait Index (DGI) as core outcome measures. Given that the BBS measures both static and dynamic balance, it was unclear as to whether either of these instruments was superior in terms of its convergent and concurrent validity, and whether there was value in complementing the BBS with the DGI. Objective: The objective was to evaluate the concurrent and convergent validity of the BBS and DGI by comparing the performance of these two functional balance tests in people with multiple sclerosis (MS). Methods: Baseline cross-sectional data on 75 people with MS were collected for use in this study from 14 physical therapy clinics participating in a large pragmatic cluster-randomized trial. Convergent validity estimates between the DGI and BBS were examined by comparing the partial Spearman correlations of each test to objective lower extremity functional measures (Timed Up and Go (TUG), Six-Minute Walk Test (6MWT), Timed 25-Foot Walk (T25FW) test) and the self-reported outcomes of physical functioning and general health using the 36-Item Short Form Health Survey (SF-36). Concurrent validity was assessed by applying logistic regression with gait disability as the binary outcome (Patient Determined Disease Steps (PDDS) as the criterion measure). The predictive ability of two models, a reduced/parsimonious model including the BBS only and a second model including both the BBS and DGI, were compared using the adjusted coefficient of determinations. Results: Both the DGI and BBS were strongly correlated with lower extremity measures overall as well as across the two PDSS strata with correlations. In PDDS ≤ 2, the difference in the convergence of BBS with TUG and DGI with TUG was −0.123 (95% CI: −0.280, −0.012). While this finding was statistically significant at a type 1 error rate of 0.05, it was not significant (Hommel’s adjusted p-value = 0.465) after accounting for multiple testing corrections to control for the family-wise error rate. The BBS–SF-36 physical functioning correlation was at least moderate and significant overall and across both PDDS strata. However, the DGI–physical functioning score did not have a statistically significant correlation within PDDS ≤ 2. None of the differences in convergent and concurrent validity between the BBS and DGI were significant. The additional variation in 6MWT explained by the DGI when added to a model with the BBS was 7.78% (95% CI: 0.6%, 15%). Conclusions: These exploratory analyses on data collected in pragmatic real-world settings suggest that neither of these measures of balance is profoundly superior to the other in terms of its concurrent and convergent validity. The DGI may not have any utility for people with PDDS ≤ 2, especially if the focus is on mobility, but may be useful if the goal is to provide insight on lower extremity endurance. Further research leveraging longitudinal data from pragmatic trials and quasi-experimental designs may provide more information about the clinical usefulness of the DGI in terms of its predictive validity when compared to the BBS.

In-vivo stiffness assessment of distal femur fracture locked plating constructs

BackgroundThe purpose of this study was to design and validate a novel stiffness-measuring device using locked plating of distal femur fractures as a model. MethodsAll patients underwent a laterally-based approach, with a bridging locked construct after indirect reduction. A custom and calibrated intraoperative stiffness device was applied and the stiffness of the construct was blindly recorded. Fourteen of twenty-seven patients enrolled with distal femur fractures (AO/OTA 33A and 33C) completed the study. Correlations between stiffness and callus formation, working length, working length/plate length ratio, number of distal locking screws, and fracture pattern were explored. FindingsCallus and modified radiographic union scale in tibias scores as a linear function of stiffness did not correlate (R2 = 0.06 and 0.07, respectively). Construct working length and working length to plate length ratio did not correlate to stiffness (R2 = 0.18 and 0.16 respectively). A combined delayed and nonunion rate was 14%. Lower extremity measure scores were not statistically different when comparing delayed and nonunion with healed fractures. InterpretationThe lack of correlation may have been due to the mechanical properties of the plate itself and its large contribution to the overall stiffness of the construct. To our knowledge, clinically relevant stiffness has not been described and this study may provide some estimates. This methodology and these preliminary findings may lay the groundwork for further investigations into this prevalent clinical problem. Other parameters not investigated may play a key role such as body mass index and bone mineral density. Level of evidenceDiagnostic/Prognostic Level II.

P.438 - Is grip strength compared to lower extremity measurements sufficient for capturing changes in muscle strength in chronic inflammatory demyelinating polyneuropathy?

P.438 - Is grip strength compared to lower extremity measurements sufficient for capturing changes in muscle strength in chronic inflammatory demyelinating polyneuropathy?

β-Amyloid Burden Predicts Lower Extremity Performance Decline in Cognitively Unimpaired Older Adults.

Motor slowing is associated with risk of Alzheimer's disease. Whether β-amyloid (Aβ) burden is associated with motor decline, independent of cognitive decline, is unknown. About 59 cognitively unimpaired older participants had baseline PET-PiB scans and repeated measures of lower (usual gait speed, 400-m time, Health ABC Physical Performance Battery (HABCPPB) score, total standing balance time) and upper (mean tapping time) extremity performance during a mean follow-up of 4.7 years. Linear mixed effect models examined the relationship between baseline Aβ burden and motor decline, adjusting for age, sex, body mass index, cardiovascular risk, APOE ɛ4 status, memory decline, depressive symptoms, ankle-arm index, processing speed, executive function, and cerebrovascular disease. Higher mean cortical Aβ burden was associated with greater declines in gait speed and HABCPPB score and a greater increase in 400-m time. Higher Aβ of putamen was associated with declines in all lower extremity measures, including balance. Higher Aβ of dorsolateral prefrontal cortex and lateral temporal lobe was associated with declines of gait speed and 400-m time, and of precuneus with a greater increase in 400-m time. Associations remained similar after further adjustment. In cognitively unimpaired older adults, Aβ burden overall and in specific brain regions are risk factors for lower extremity motor decline, independent of memory function. These findings provide the first empirical evidence that Aβ burden is a risk factor for mobility decline in older adults.

The agreement between oscillometric and intra-arterial technique for blood pressure monitoring in the lower extremities for infants and toddlers undergoing aortic coarctation repair.

Anesthetic management for patients undergoing surgical repair of aortic coarctation (CoA) should include constant blood pressure monitoring of the right upper extremity and a lower extremity. The delayed or absent pulse in the lower limbs often leads to unsuccessful arterial cannulation in infants and the oscillometric technique used for blood pressure measurement. The aim of this study was to evaluate the agreement between the oscillometric method and intra-arterial technique for blood pressure monitoring in the lower limbs of infants undergoing CoA. A total of 45 infants diagnosed with isolated CoA were initially enrolled in this study and five were excluded because of cannulation failure. Thus, 40 patients had their blood pressure measured simultaneously by both oscillometric technique on the thigh and femoral artery catheterization. After induction and intubation, five pairs of blood pressure readings from each patient were collected in an interval of 3 min. Statistical analysis was accomplished by revised Bland-Altman analysis. There was a strong correlation between oscillometric and invasive blood pressure measurements [systolic blood pressure (SBP) r = 0.771, diastolic blood pressure (DBP) r = 0.704 and mean artery pressure (MAP) r = 0.850]. The mean difference and 95% limits of agreement (95% LOA) between oscillometric and femoral artery blood pressure readings was 3.830 mmHg (-19.297, 26.957) for SBP, -8.725 mmHg (-26.236, 8.786) for DBP, and -3.235 mmHg (-18.842, 12.372) for MAP. There were only one pair of MAP (1/40) and two pairs of SBP readings (2/40) out of range (95% LOA), and all of paired DBP readings were within 95% LOA. There was a good agreement between oscillometric and invasive blood pressure measurements of lower extremities in infants with isolated CoA statistically. However, the oscillometry-measured SBP showed a tendency to overestimate the intra-arterial blood pressure reference, while oscillometry-measured DBP underestimated its reference. MAP measurement provided the most accurate and reliable results in this study.

Lower Extremity Measurements in the Prediction of Body Height of the Igbos

Lower Extremity Measurements in the Prediction of Body Height of the Igbos

Cross-Cultural Adaptation and Validation of the Lower Extremity Measure Into German

Introduction:The Lower Extremity Measure (LEM) was developed to provide a specific instrument to detect changes in physical function in patients with hip fracture. Of 29 questions, 3 have a valid “not applicable” answer option. The goal of this study was to validate the LEM in German and to determine the added value to the physical functioning (pf) subscale of the Short Form 36 (SF-36).Materials and Methods:The LEM was translated according to published guidelines and administered to patients with hip fracture (31 A1-A3 and 31 B1-B3) shortly after surgery (baseline), at 3 months (3M), and for reliability testing at 3 months plus 1 week (3M+). The reproducibility, internal consistency, floor and ceiling effects, construct validity, and responsiveness of the German LEM were assessed.Results:A total of 106 patients completed the LEM and SF-36 (mean age 75.5; 67% women) at baseline (mean of 4.9 days after operation), and 88 completed both questionnaires at both the 3M and 3M+ assessments. At each assessment time point, between 6% and 23% of the patients answered 7 questions as “not applicable.” Reproducibility and internal consistency were high (intraclass correlation coefficient = 0.93; Cronbach's α = .96). No floor effect (0%) and a minor ceiling effect (7.87%) were found for the total LEM score. The strongest correlation was found between the LEM and the SF-36 subscale pf (Spearman ρ = .93). Responsiveness was similar for the SF-36 pf subscale and the LEM when using effect size (SF-36 pf 0.71 vs LEM 0.72) and better for the LEM when using standardized response mean (SF-36 pf 0.65 vs LEM 0.76).Discussion:The German LEM is a reliable, valid, and responsive measure for the self-assessment of patients after hip fracture surgery. As a number of questions are not applicable to elderly patients, the added value of this lengthy questionnaire in these often frail, sometimes cognitively impaired patients is still open for debate.

Reliability of a new method for lower-extremity measurements based on stereoradiographic three-dimensional reconstruction

Several clinical and radiological techniques have been described to assess lower limb length and angle measurements. None of them has yet met the ideal criteria for a reliable, reproducible, safe, and inexpensive system. In this context, a new biplanar X-ray system (EOS™, EOS imaging, Paris, France) makes it possible to obtain a 3D reconstruction of the lower extremities from two 2D orthogonal radiographic images, with associated calculation of 3D measurements. The reliability of this technique has never been documented on adults. Lower limb measurements produced by the 3D EOS™ reconstruction system are reproducible regarding inter- and intraobserver assessment and more reliable with this 3D technique than when they are obtained from 2D measurements. This study included 25 patients awaiting total hip arthroplasty (50lower limbs). Two independent observers made all measurements twice, both on the 2D frontal radiograph and using 3D reconstructions (femoral measurements of length, offset, neck shaft angle, neck length, and head diameter, as well as the tibia length, limb length, HKA and HKS). Reproducibility was estimated by intraclass correlation coefficients. Both the inter- and intraobserver reproducibility of the EOS™ measurements was excellent; more specifically inter- and intraobserver reproducibility was 0.997 and 0.997 for femoral length, 0.996 and 0.995 for tibial length, 0.999 and 0.999 for limb length, 0.894 and 0.891 for HKS, 0.993 and 0.994 for HKA, 0.870 and 0.845 for femoral offset, and 0.765 and 0.851 for neck shaft angle. For most of the variables, the interobserver correlations were statistically better with the EOS™ 3D reconstruction. Our results show that the EOS™ systems allow reproducible lower limb measurements. Furthermore, 3D EOS™ reconstructions offer better reproducible measures for most of the parameters than radiographic 2D projection. Its use before deciding on surgery and during planning for lower limb arthroplasty appears essential to us. Level III: diagnostic prospective study on consecutive patients.

The Timed Up and Go Test Is an Early Predictor of Functional Outcome After Hemiarthroplasty for Femoral Neck Fracture

The ability to predict the long-term physical function and prognosis of hip fracture patients during the early postoperative period is essential for surgeons and physical therapists as well as for patients and their families. The purpose of this study was to determine whether early functional assessment correlated with and/or predicted long-term function after surgery to treat a displaced femoral neck fracture. Sixty-two patients undergoing hemiarthroplasty for a displaced femoral neck fracture were evaluated prospectively; a minimum follow-up of two years was required. Validated functional assessments, including the Lower Extremity Measure and the Timed Up and Go test, were utilized, and scores were analyzed with respect to patient baseline data. The functional level of patients decreased significantly after the injury, with the mean Lower Extremity Measure score decreasing from 87.7 to 62.4 and the need for a walking aid increasing from 36% to 54% at two years postoperatively (p < 0.05 for both). The Timed Up and Go test scores at four days and three weeks postoperatively were significantly higher in patients who needed a walking aid at two years compared with independently walking patients (p < 0.05). Receiver operating characteristic curve analysis of the Timed Up and Go test scores revealed that the optimal threshold for predicting the need for a walking aid at two years was fifty-eight seconds at four days postoperatively and twenty-six seconds at three weeks. Also, the need for a walking aid at two years was ninetyfold higher when the Timed Up and Go test score at three weeks postoperatively exceeded the twenty-six seconds threshold. The Timed Up and Go test was an early clinical indicator of future physical function in patients with a hip fracture treated with hemiarthroplasty. Innovative clinical approaches to anticipate future function will contribute to increasing the efficiency of overall management of this growing set of patients.

Analysis of vertical ground reaction force variables during a Sit to Stand task in participants recovering from a hip fracture

BackgroundA Sit to Stand task following a hip fracture may be achieved through compensations (e.g. bilateral arms and uninvolved lower extremity), not restoration of movement strategies of the involved lower extremity. The primary purpose was to compare upper and lower extremity movement strategies using the vertical ground reaction force during a Sit to Stand task in participants recovering from a hip fracture to control participants. The secondary purpose was to evaluate the correlation between vertical ground reaction force variables and validated functional measures. MethodsTwenty eight community dwelling older adults, 14 who had a hip fracture and 14 control participants completed the Sit to Stand task on an instrumented chair designed to measure vertical ground reaction force, performance based tests (Timed up and go, Berg Balance Scale and Gait Speed) and a self report Lower Extremity Measure. A MANOVA was used to compare functional scales and vertical ground reaction force variables between groups. Bivariate correlations were assessed using Pearson Product Moment correlations. FindingsThe vertical ground reaction force variables showed significantly higher bilateral arm force, higher uninvolved side peak force and asymmetry between the involved and uninvolved sides for the participants recovering from a hip fracture (Wilks' Lambda=3.16, P=0.019). Significant correlations existed between the vertical ground reaction force variables and validated functional measures. InterpretationParticipants recovering from a hip fracture compensated using their arms and the uninvolved side to perform a Sit to Stand. Lower extremity movement strategies captured during a Sit to Stand task were correlated to scales used to assess function, balance and falls risk.

Three-Column Fixation for Complex Tibial Plateau Fractures

1) To introduce a computed tomography-based "three-column fixation" concept; and 2) to evaluate clinical outcomes (by using a column-specific fixation technique) for complex tibial plateau fractures (Schatzker classification Types V and VI). Prospective cohort study. Level 1 trauma center. Twenty-nine cases of complex tibial plateau fractures were included. Based on routine x-ray and computed tomography images, all the fractures were classified as a "three-column fracture," which means at least one separate fragment was found in lateral, medial, and posterior columns in the proximal tibia (Schatzker classification Types V and VI). The patients were operated on in a "floating position" with a combined approach, an inverted L-shaped posterior approach combined with an anterior-lateral approach. All three columns of fractures were fixed. Operative time, blood loss, quality of reduction and alignment, fracture healing, complications, and functional outcomes based on Hospital for Special Surgery score and lower-extremity measure were recorded. All the cases were followed for average 27.3 months (range, 24-36 months). All the cases had satisfactory reduction except one case, which had a 4-mm stepoff at the anterior ridge of the tibial plateau postoperatively. No case of secondary articular depression was found. One case had secondary varus deformity, one case had secondary valgus deformity, and two cases of screw loosening occurred postoperatively. No revision surgery was performed. Two cases had culture-negative wound drainage. No infection was noted. The average radiographic bony union time and full weightbearing time were 13.1 weeks (range, 11-16 weeks) and 16.7 weeks (range, 12-24 weeks), respectively. The mean Short Form 36, Hospital for Special Surgery score, and lower-extremity measure at 24 months postoperatively were 89 (range, 80-98), 90 (range, 84-98), and 87 (range, 80-95), respectively. The average range of motion of the affected knee was 2.7° to 123.4° at 2 years after the operation. Three-column fixation is a new fixation concept in treating complex tibial plateau fractures, which is especially useful for multiplanar fractures involving the posterior column. The combination of posterior and anterior-lateral approaches is a safe and effective way to have direct reduction and satisfactory fixation for such difficult tibial plateau fractures.