Non-weight Bearing Research Articles

Weight-bearing status may influence rates of radiographic healing following reamed, intramedullary fixation of diaphyseal femur fractures.

Objective:To investigate the effect of weight-bearing status on radiographic healing of diaphyseal femur fractures.Design:Retrospective 1:1 matched cohort study.Setting:Single-level 1 trauma center.Participants:One-hundred forty-four (N = 154) patients matched 1:1 in non-weight bearing (NWB) and weight-bearing as tolerated (WBAT) groups.Intervention:Non-weight bearing following reamed, statically locked intramedullary fixation of diaphyseal femur fracture, generally due to concurrent lower extremity fracture.Main Outcome Measurement:Postoperative radiographic healing using modified Radiographic Union Scale for Tibia fractures (mRUST) scores.Results:Groups were well matched on age, sex, race, prevalence of tobacco and alcohol use, diabetes mellitus status, Injury Severity Score, fracture pattern and shaft location, vascular injury, open fracture prevalence, and operative characteristics. Radiographic follow-up was similar between groups (231 vs 228 days, P = .914). At 6 to 8 weeks status post intramedullary fixation, the median mRUST score in the NWB group (9) was lower than that of the WBAT group (10) (mean: 8.4 vs 9.7, P = .004). At 12 to 16 weeks, the median mRUST in the NWB group (10) was again lower than the WBAT group (12) (mean: 9.9 vs 11.7, P = .003). The median number of days to 3 cortices of bridging callous was 85 in the WBAT group, compared with 122 in the NWB group (P = .029). Median time to mRUST scores of 12 (111 vs 162 days, P = .008), 13 (218 vs 278 days, P = .023), and 14 (255 vs 320 days, P = .028) were all longer in the NWB group compared with the WBAT group.Conclusions:Non-weight bearing after intramedullary fixation of diaphyseal femur fractures delays radiographic healing, with median time to 3 cortices of bridging callous increased from 85 days in WBAT groups to 122 days in NWB groups. These results provide clinicians with an understanding of the expected postoperative course, as well as further support the need to expeditiously advance weight-bearing status.Level of Evidence: IV

The non-weight bearing pathway: A community based alternative to inpatient rehabilitation

Purpose: In England, over 4.5 million bed days are used annually for admissions related to falls and fractures in older adults. Immobility in older adults poses an additional health risk. Those considered frail are at greater risk of suddenly deteriorating both physically and mentally. Many patients develop decreased confidence, social isolation and an increased reliance on social care and family, thus preventing complications is essential. Fractures designated Non-Weight Bearing (NWB) are challenging to manage in an ageing population and therefore, an NWB initiative was developed to provide early facilitated discharge and rehabilitate patients at home.

UNUSUAL ANKLE FRACTURE: A LITERATURE REVIEW

Background:- Fractures of the talus are unusual, and talar body fractures in the sagittal plane are still rarer. Its treatment aims a crucial anatomic reduction to reimpose congruency of the ankle and decrease the risk of avascular necrosis by conserving any remaining blood supply. We present the case of a body talar fracture in the sagittal plane related to fracture of the medial malleolus in an adult. The mechanism of the fracture was, internal rotation, plantar hyperexion, and axial compression. We performed an open reduction and stabilization with two screws for the talus and screwed the medial malleolus. Material & Methods:- We included 30 patients in this study among which a 25 years old man presented in Department Of Orthopaedics, Mgmmch, Jamsehedpur, Jharkhand with a grossly expand and deformed right ankle. Radiographs revealed a displaced vertical fracture of the neck of the talus traversing through the body with vertical fracture of the medial malleolus and medial talar shift. Results:- Fractures of the talus have a relatively little incidence accounting for 0.3% of all bone fractures and 3% to 6% of all foot fractures.[1,2] Union of the fracture in such a case is extremely slow as it depends on a new blood supply growing into the avascular bone.[3] Hence, the fracture needs preservation for a long time, and non-weight bearing is recommended for three months or until the union has occurred. Malunion can produce substantial alteration in load across the ankle and subtalar joints and result in arthrosis. The reported case should have the best prognosis as it was closed and underwent immediate operative reduction with early signs of revascularization. After 13 months following the injury, the patient had the best range of movement with some pain. Conclusion:- Talar body fracture associated with ankle fracture is very rare. Still, the malleolar fracture that allows adequate visualisation, anatomical reduction, and appropriate fracture xation can give us hope to reduce complications.

Do Weight-Bearing Knee Digital Radiographs Help to Track the Severity of OA?

Weight-bearing radiographs are preferred for joint space width (JSW) assessment in OA, sometimes non-weight-bearing radiographs are also done. This study aims to evaluate (1) The knee JSW in weight-bearing (WB) and non-weight-bearing (NWB) X-ray images. (2) Quadriceps angle (Q angle) at weight-bearing and non-weight-bearing positions. Patients above 50years old with symptoms (knee pain, functional limitations, and crepitus) from April 2019 to November 2019 were included in the study. Expert exclude patients with post-surgical evaluation, trauma, and infection. JSW and Q angle measurements with respect to weight-bearing and non-weight-bearing positions were made by the same medical expert to avoid inter-observer variation. Medial knee JSW varies from 0.49 to 5.75mm in weight-bearing radiograph and 0.53mm to 6.16mm in non-weight-bearing radiograph. Q angle varies from 8.72° to 14.58° in weight-bearing position and 10.13° to 14.92° in non-weight-bearing position. Q angle (< 11.72°) and medial JSW (< 3.725mm) were found to be significantly associated with the rapid progression of knee varus OA (p < 0.001). NWB digital X-ray images overestimate early and underestimate severe OA. There is a possibility of increasing tibia internal rotation and reduction of joint space width in a standing position (WB) as the phase of knee OA diagnosis. These findings show that weight-bearing knee joint radiographs are helpful to track the progression of knee varus OA and have strong clinical usage than non-weight-bearing radiographs. Patients whose Q angle and knee JSW measures are below the limitations need more attention.

Conservative management of Jones fractures with immediate weight-bearing in a walking boot demonstrates healing

Jones fractures, or proximal metatarsal fractures at the level of the fourth and fifth intermetatarsal junction, have a high risk for nonunion due to a vascular watershed region. Classically, treatment consists of weight bearing restrictions in a cast or surgical fixation. Some studies have assessed immediate weight bearing following a Jones fracture. Due to conflicting results, the most appropriate treatment method remains unclear. This study analyzes outcomes after treating adults with acute Jones fractures non-operatively without weight bearing restrictions in a walking boot. This study hypothesizes that patients will not require future operative intervention following functional treatment.A retrospective review of 55 adult patients who sustained acute, closed Jones fractures was conducted. 47 were treated weight bearing as tolerated (WBAT) in a walking boot and eight were treated non-weight bearing (NWB) in a cast. They were followed radiographically by an orthopedic surgeon for an average of 6.4 and 15.5 months, respectively.Three patients in each group (6.4% WBAT, 37.5% NWB) developed painful nonunion leading to surgical fixation. Thirty (66.7%) patients in the WBAT group demonstrated radiographic union on final radiographs. Only two (13.3%) of the 15 patients with partial union were seen at least six months from time of injury, one of whom had ongoing pain but declined surgery. The remaining 13 patients were asymptomatic at their final clinic appointment.Controversy still exists as to the best treatment methodology for acute Jones fractures. Due to a lack of clear guidelines, it can be difficult for the multiple medical specialties involved to evaluate and treat this injury. Our study suggests that non-operative management of minimally displaced Jones fractures, in the adult, low demand population, without weight bearing restrictions in a walking boot offers similar outcomes to cast immobilization with weight bearing restrictions, resulting in bony union or asymptomatic fibrous nonunion.

Charcot ankle arthrodesis with retrograde nailing: Case report

Charcot neuroarthropathy is a destructive disease. It is very important to recognize early; and with appropriate management can prevent catastrophic outcomes. Delaying the diagnosis often preclude successful conservative management of these deformities which necessitate surgical intervention for limb salvage. Materials and Methods: We review the current literature on surgical reconstruction of Charcot neuroarthropathy and present a case report of ankle arthrodesis with retrograde nail after evaluating the patient with complains of deformity of left ankle clinically, radiologically who came to KIMS Hospital and research centre.Surgical management: The primary indication for surgical reconstruction is deformity associated with instability. Other indications include impending ulceration, osteomyelitis, presence of in and/or significant pain. Arthrodesis of the ankle is the method of choice when surgically correcting Charcot Neuropathy deformities. The choice of fixation (i.e. internal or external fixation) depends on largely on the presence or absence of active infection and bone quality.Conclusion: Surgical reconstruction of ankle CN is associated with a high rate of infectious and noninfectious complications. Despite this high complication rate, surgeons recommended on surgical reconstruction of ankle CN should strive for limb salvage rates approximating 90% with non-weight bearing mobilization for atleast 6 months with fusion taking upto 11 months.

Does the Nonweightbearing Foot Position Replicate the Neutral Calcaneal Stance Position in an Adult Population?

The neutral calcaneal stance position (NCSP), despite its known issues, is currently used as an "ideal" measure compared with the resting stance position in clinical podiatric medicine. The nonweightbearing (NWB) foot position, as used in the foot mobility magnitude (FMM), can provide an alternative comparative position, which is partially validated, if a significant correlation between the NCSP and the NWB position exists. This study aimed to establish the correlation between the component measures of the FMM in the NCSP and the NWB foot position of the FMM. Eighty participants were recruited. Measures of dorsal arch height (DAH) and midfoot width (MFW) were obtained at the 50% total foot length mark in the NCSP and the NWB position by two examiners using the apparatus described by McPoil et al. Reliability analysis with intraclass correlation coefficients (ICCs) indicated intrarater results of 0.90 to 0.99 for DAH and 0.96 to 0.99 for MFW and interrater results of 0.90 for DAH and 0.96 for MFW in the NWB position. Using a Pearson product moment correlation coefficient analysis, there was a significant correlation between the NCSP and the NWB position for DAH (r = 0.82) and MFW (r = 0.86). A significant correlation between the NCSP and the NWB position was evident when the measures of DAH and MFW were conducted. Therefore, clinically, the NWB position can potentially replace the NCSP as the ideal position for clinical treatment.

Impact of Early Weightbearing After Ankle Arthroscopy and Bone Marrow Stimulation for Osteochondral Lesions of the Talus.

Background:Osteochondral lesion of the talus (OLT) may be caused by osteochondritis dissecans, osteochondral fractures, avascular necrosis, or focal arthritic changes. For certain focal cartilage defects, bone marrow stimulation (BMS) has been a widely used technique to restore a fibrocartilage substitute overlying the defect. There are various postoperative weightbearing protocols for this procedure, with no single gold standard method.Purpose:To retrospectively review the outcomes of patients undergoing ankle arthroscopy with concomitant BMS to determine outcomes based on postoperative weightbearing status.Study Design:Cohort study; Level of evidence, 3.Methods:We retrospectively reviewed the records of patients who underwent ankle arthroscopy with BMS for OLTs between 2015 and 2018. Patients were placed into 2 cohorts based on postoperative immobilization status: the nonweightbearing (NWB) group and the weightbearing-as-tolerated (WBAT) group. Patient characteristics obtained included age, sex, comorbidities, and etiology of talar pathology. Outcomes included the pain visual analog scale (VAS), range of motion (ROM), complications, time to first weightbearing, and the method and length of immobilization. Patients who were lost to follow-up before 30 days were excluded. The chi-square test was used to compare categorical variables between cohorts, and the t test was used for continuous variables.Results:A total of 69 patients met the inclusion criteria for this study, 18 in the WBAT group and 51 in the NWB group. The mean lesion size was 9.48 × 9.21 mm (range, 3-15 mm × 2-20 mm) for the NWB group and 9.36 × 9.72 mm (range, 5-14 mm × 6-20 mm) for the WBAT group (P > .05). The VAS scores improved from 4.40 to 0.67 for the WBAT group and from 6.33 to 2.55 for the NWB group, with the difference in final values reaching statistical significance (P = .0002). Postoperative ROM was not significantly different between the groups. There were 4 repeat operations within the NWB cohort.Conclusion:The surgical management of OLTs can be challenging, and the postoperative weightbearing protocol can be an extra obstacle for the patient to navigate. We found no difference in pain, ROM, or complications when allowing immediate, full WBAT.

Primary total knee replacement for tibial plateau fractures in older patients: a systematic review of 197 patients

IntroductionTibial plateau fractures are typically treated with osteosynthesis. In older patients, osteosynthesis is associated with some complications, risk of post-traumatic osteoarthritis and long partial, or non-weight bearing during the recovery phase. To avoid these problems, primary total knee replacement (TKR) has become an increasingly common treatment option. The aim of this study was to evaluate all the relevant literature and summarize the current evidence-based knowledge on the treatment of tibial plateau fractures with primary TKR in older patients.Materials and methodsA systematic literature search of studies on total knee replacement (TKR) as primary treatment for acute traumatic tibial plateau fracture was conducted using OVID Medline, Scopus, and Cochrane databases from 1946 to 18 November 2019. We included all studies without restrictions regarding total knee replacement (TKR) as primary treatment for acute traumatic tibial plateau fracture.ResultsOf the 640 reviewed articles, 16 studies with a total of 197 patients met the inclusion criteria. No controlled trials were available, and the overall quality of the literature was low. The results, using different clinical scoring systems, were good or fair. Four-year follow-up complication (6.1%) and revision (3.6%) rates after primary TKR appeared to be lower than after secondary TKR (complication rate 20–48%, revision rate 8–20%) but higher than after elective primary TKR.ConclusionBased on low-quality evidence, TKR appears to be a useful treatment option for tibial plateau fractures in older patients. Controlled trials are mandatory to determine the relative superiority of these two options as primary treatment of tibial plateau fractures in older patients.

Weight-bearing knee flexion angle better correlates with patient-reported outcome measures than non-weight-bearing condition in total knee arthroplasty: a three-dimensional analysis study

BackgroundThis study aims to elucidate and compare the relationship between the knee flexion angle and patient-reported outcome measures (PROM) in both non-weight-bearing (NWB) and weight-bearing (WB) conditions.MethodsThis retrospective cohort study included 61 knees (47 patients) who underwent total knee arthroplasty. The knee flexion angle was measured by three conditions: NWB in manual goniometer, NWB in fluoroscopic three-dimensional (3D) analysis and WB in the fluoroscopic 3D analysis. The PROM was evaluated by postoperative 2011 Knee Society Score (2011 KSS) and Knee injury and Osteoarthritis Outcome Score (KOOS). Correlations between the knee flexion angle and PROM was analyzed using Spearman’s correlation coefficient. Additionally, whether the angular difference between NWB and WB correlated with the PROM or not was evaluated.ResultsThe NWB knee flexion angle in a goniometer, NWB in 3D analysis, and WB in 3D analysis were 124.6° ± 8.4°, 118.0° ± 10.5°, and 109.5° ± 13.3°, respectively. The angular difference was 8.5° ± 12.8°. No PROM correlation existed in NWB using a goniometer. Moreover, significant positive correlations in 2011 KSS symptoms (r = 0.35) and 2011 KSS functional activities (r = 0.27) were noted in NWB using 3D analysis. Significant positive correlations existed in 2011 KSS symptoms (r = 0.32), 2011 KSS functional activities (r = 0.57), KOOS pain (r = 0.37), KOOS activity of daily living (ADL; r = 0.45), KOOS sports (r = 0.42), and KOOS quality of life (r = 0.36) in WB using 3D analysis. Significant negative correlations were noted in 2011 KSS functional activities (r = − 0.45), KOOS ADL (r = − 0.30), and KOOS sports (r = − 0.38) in angular difference.ConclusionsThe WB knee flexion angle better correlated with PROM compared with NWB by evaluation of 3D analysis. The larger the angular difference existed between NWB and WB, the lower the PROM score.

Comparison of Weightbearing and Nonweightbearing Juvenile Osteochondritis Dissecans Lesions of the Lateral Femoral Condyle.

Background:Repetitive microtrauma may contribute to osteochondritis dissecans (OCD) lesions of the femoral condyle. The effect of differential loading between OCD weightbearing (WB) zones has not been studied.Purpose:To determine whether clinical and radiographic variables differ by WB zone in lateral femoral condyle OCD lesions.Study Design:Cohort study; Level of evidence, 3.Methods:We retrospectively reviewed a consecutive series of patients aged <18 years with lateral femoral condyle OCD lesions presenting at a single institution between 2004 and 2018. Patients with OCD lesions outside of the lateral femoral condyle were excluded. Lesions were localized on radiographs using the Cahill and Berg classification, referencing the Blumensaat line and an extension of the posterior femoral cortex. Progeny bone characteristics evaluated at baseline and 24-month follow-up included ossification, distinct borders from parent bone, and displacement. Baseline lesion dimensions were measured on magnetic resonance imaging (MRI) scans. We evaluated posttreatment pain level, return-to-activity rate, and patient-reported outcome measures (PROMs) including the Pediatric International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, and Pediatric Functional Activity Brief Scale.Results:A total of 62 lateral femoral condyle OCD lesions (mean follow-up, 24.1 months) presented within the study period: 26 WB lesions and 36 nonweightbearing (NWB) lesions. At presentation, no differences between the lesion types were observed in symptom chronicity or symptomatology. NWB lesions were deeper on MRI scans (sagittal depth, 7.11 vs 5.96 mm; P = .046; coronal depth ratio, 0.05 vs 0.01 mm; P = .003), were more likely to develop progeny bone (69.4% vs 44%; P = .047), and demonstrated higher radiographic healing rates (52.8% vs 24%; P = .025) compared with WB lesions. PROMs at follow-up were available for 25 of 62 patients (40.3%), with no statistically significant differences between cohorts at any time. Return to full activity was observed in 72% of WB and 82.1% of NWB lesions (P = .378).Conclusion:Lateral femoral condyle OCD lesions of the knee in WB and NWB zones presented similarly at initial evaluation; however, NWB lesions demonstrated higher rates of progeny bone formation and radiographic healing at mean 2-year follow-up.

Hip Pain-Cross Country

Title:Hip Pain-Cross Country Keywords:Hip pain, stress fracture, femur HISTORY: A 15 year old female cross country runner presented with 3 weeks of right groin and knee pain. She started cross country for the first time this year and had a significant increase in her mileage, from 2 miles per day over the summer up to 6 miles per day with the start of the season. On presentation, patient was experiencing pain with both walking and running and pain improved with rest. She had been on crutches for one week and had minimal improvement in her pain. She described the pain as radiating down her leg. There was no numbness, tingling or weakness in her leg. PHYSICAL EXAMINATION: Patient was alert and in no acute distress at rest. She had an antalgic gait. Right hip and knee had no soft tissue swelling or bruising. No tenderness over the pelvic region, adductors or abductors, quadriceps or hamstrings. No pain over the knee joint lines. Full, painless range of motion of the hip and knee. 4+/5 strength to hip adduction with mild pain. Full strength in all other planes without pain. Pain with right leg hop test. DIFFERENTIAL DIAGNOSIS: 1. Adductor strain 2. Apophyseal Avulsion Fracture 3. Stress fracture TESTS AND RESULTS: Radiographs, right knee, AP, lateral and sunrise-Normal alignment, no acute bony abnormalities, the patient has reached skeletal maturityRadiographs, right hip, AP pelvis and frog-leg hip-No acute bony abnormalities, normal alignmentMRI, right femur-Stress fracture of the femoral diaphysis with associated marrow edema and periosteal edema FINAL/WORKING DIAGNOSIS: Stress fracture of the femoral diaphysis TREATMENT AND OUTCOMES: 1. Non-weight bearing on crutches for 3 weeks followed by a gradual transition to one crutch and then full weight bearing when she was pain free. 2. Rehab with the school athletic trainer as well as physical therapy 3. With clinical and radiographic signs of healing at week 7, patient progressed to the stationary bike and then elliptical over the next three weeks. 4. She started jogging at week 11 and slowly added 10% distance/intensity per week 5. Athlete returned to her winter sport, basketball, 12 weeks after injury and continues to do well

Prevalence of Plantar Fasciitis Among Nurses at A Tertiary Care Centre in A Rural Area: A Cross Sectional Study

Background: The plantar fascia can further encounter a form of pathological degeneration called as plantar fasciitis that is one of the most common causes of heel pain. Plantar fasciitis is a multifactorial in origin and works as a mechanical overloading reaction to multiple instances of microtrauma. Purpose: This research will rule out the prevalence of plantar fasciitis in nurses both male and female with the help of windlass test and also make us aware about the correlation of plantar fasciitis among males and females. Methodology: A simple random sampling of 100 healthy nurses, 70 female nurses and 30 male nurses from Pravara Institute, Loni was included. The participants included were between age group of 20-50 years and were screened according to inclusion and exclusion criteria. Windlass test was performed in all the recruited participants. The test was done both in non-weightbearing (NWB) and weightbearing (WB) position. If pain was reproduced, the subject then marked the location of the pain. If pain was provoked then the test was considered positive. Result: The windlass test (weight bearing and non-weight bearing) showed that out of 100 participants 21% tested positive; out of which 17% females and 4% males responded positive in the study. Conclusion: The study concluded that female nurses are more prone to develop plantar fasciitis when compared with male nurses. KEY WORDS: Plantar fascia, Plantar fasciitis, Plantar fascia thickness, Pain, Nurses, Windlass test.

Hip Osteonecrosis in Pediatric Leukemia/Lymphoma Patients Treated with Glucocorticoids: Retrospective Analysis in a Single Institute

IntroductionBecause the survival rate of patients with pediatric lymphoblastic leukemia (ALL) has improved in the last five decades, more emphasis has been placed on reducing the adverse side effects of its treatment without compromising on the rate of recovery or chance of survival. Glucocorticoid-induced osteonecrosis (ON) is one of the late complications of ALL treatments, affecting the patients' quality of life. Previous reports indicate that it occurs in up to 50% of children treated for pediatric ALL/lymphoblastic lymphoma (LBL). Joints generally collapse within 2 years of ON identification when it affects more than 30% of the epiphyseal surface, defined herein as extensive ON. Kaste et al. reported the utility of early screening magnetic resonance imaging (MRI) for detecting extensive hip ON and demonstrated its high incidence in patients older than 10 years (J Clin Oncol 33:610-615, 2015). However, there are very few data from Asian studies validating the same. Thus, in this study, we investigated the incidence of hip ON in ALL patients at a single institution in Japan.MethodsWe retrospectively analyzed the rate of incidence of hip ON in Japanease pediatric ALL/LBL patients who were treated with glucocorticoids from January 2003 to May 2017 at our institution. We performed hip MRI screenings at the beginning of maintenance therapy. In patients with radiological ON detected by MRI screening, a follow-up MRI was performed at the end of the maintenance therapy. Overall, 158 patients underwent hip MRI screening at the beginning of the maintenance chemotherapy. The study group comprised 84 males and 74 females, and the median age at diagnosis was 6.5 years (range: 1-22 years).ResultsAt the beginning of the maintenance chemotherapy, asymptomatic hip ON, which was detected by MRI screening, was identified in 10 patients (6.3%), and symptomatic hip ON was identified in 1 patient (0.6%)-a 13-year-old girl with T-cell-ALL. Only 1 of 113 (1%) children who were 10 years or younger had ON, whereas 10 of 45 (23.2%) children who were older than 10 years had ON, and there was a statistical difference between these 2 groups (p = 1.38 × 10-5). There was no statistical difference based on dexamethasone treatment or gender. Of the 10 patients with asymptomatic hip ON, 3 patients (27%) had lesions defined as extensive hip ON. All 10 patients were only observed during the maintenance therapy without special orthopedic management, and a follow-up MRI indicated disease progression in 2 patients. The necrotic lesion remained stable in 4 patients, whereas it improved or completely disappeared in 4 others. Of the 4 patients with stable lesions, 2 patients experienced pain after completion of the maintenance chemotherapy. Although the condition of the patient with symptomatic ON was managed with non-weight bearing therapy, the symptoms worsened and hip joint replacement has now been suggested for this patient.ConclusionsAs reported previously, the incidence of asymptomatic hip ON in patients older than 10 years is considerably high. The incidence of hip symptomatic ON in Japanese children and adolescents older than 10 years was lower the incidence reported previously in other populations [ J Clin Oncol 33:610-615, 2015]. Germline genetic basis might have relationship to ON. To further investigate the change of asymptomatic ON to symptomatic ON, nationwide longer follow-up studies are needed. DisclosuresNo relevant conflicts of interest to declare.

Functional bracing is a safe and cost effective treatment for isolated Weber B fracture

BackgroundDespite the current recommendations that stable Weber B ankle fractures can be treated with functional bracing and weightbearing as tolerated, some reluctance exists among trauma surgeons to follow these recommendations. This paper reports on our institution’s experience in managing these injuries and compare it to the national guidelines. Patients and methodsThis is a retrospective cohort study. Consecutive patients with isolated Weber B fractures referred to the local outpatient clinic over the period of six months were included in the study. Radiographs and clinic letters were examined, the patients were interviewed via telephone to obtain outcome scores [Olerud and Molander score]. Method of immobilisation, weight-bearing status, radiological fracture union, clinical outcomes and complications were all assessed and analysed. ResultsOne hundred and twenty-three patients with isolated Weber B fractures were identified. This cohort of patients did not show clinical or radiographic evidence of instability, they were deemed stable and were initially treated non-operatively. Minimum follow-up period was six months. Sixty-two patients were treated in plaster and were non-weight bearing on the affected limb, while 61 were treated with functional bracing in a boot and were allowed early weight bearing. Three patients showed displacement requiring surgical fixation. All fractures progressed to union and patients were discharged irrespective of the method of immobilisation or weightbearing status during treatment. There was no statistically significant difference in the functional outcome measures between the two groups. The protocol of functional bracing and weightbearing was associated with fewer outpatient clinics and a reduced number of radiographs obtained in the clinic and fewer complications. ConclusionIsolated trans-syndesmotic Weber B ankle fractures, that are clinically and radiologically stable, can be safely treated with functional bracing in a boot and weightbearing as tolerated.

Is postoperative non-weight-bearing necessary? INWN Study protocol for a pragmatic randomised multicentre trial of operatively treated ankle fracture

BackgroundPostoperative management regimes vary following open reduction and internal fixation (ORIF) of unstable ankle fractures. There is an evolving understanding that extended periods of immobilisation and weight-bearing limitation may lead to poorer clinical outcomes. Traditional non-weight-bearing cast immobilisation may prevent loss of fixation, and this practice continues in many centres. The purpose of this trial is to investigate the safety and efficacy of immediate weight-bearing (IWB) and range of motion (ROM) exercise regimes following ORIF of unstable ankle fractures with a particular focus on functional outcomes and complication rates.MethodsA pragmatic randomised controlled multicentre trial, comparing IWB in a walking boot and ROM within 24 h versus non-weight-bearing (NWB) and immobilisation in a cast for 6 weeks, following ORIF of all types of unstable adult ankle fractures (lateral malleolar, bimalleolar, trimalleolar with or without syndesmotic injury) is proposed. All patients presenting to three trauma units will be included. The exclusion criteria will be skeletal immaturity and tibial plafond fractures. The three institutional review boards have granted ethical approval. The primary outcome measure will be the functional Olerud-Molander Ankle Score (OMAS). Secondary outcomes include wound infection (deep and superficial), displacement of osteosynthesis, the full arc of ankle motion (plantar flexion and dorsal flection), RAND-36 Item Short Form Survey (SF-36) scoring, time to return to work and postoperative hospital length of stay. The trial will be reported in accordance with the CONSORT statement for reporting a pragmatic trial, and this protocol will follow the SPIRIT guidance.DiscussionTraditional management of operatively treated ankle fractures includes an extended period of non-weight-bearing. There is emerging evidence that earlier weight-bearing may have equivocal outcomes and favourable patient satisfaction but higher wound-related complications. These studies often preclude more complicated fracture patterns or patient-related factors. To our knowledge, immediate weight-bearing (IWB) following ORIF of all types of unstable ankle fractures has not been investigated in a controlled prospective manner in recent decades. This pragmatic randomised-controlled multicentre trial will investigate immediate weight-bearing following ORIF of all ankle fracture patterns in the usual care condition. It is hoped that these results will contribute to the modern management of ankle fractures.Trial registrationISRCTN Registry ISRCTN76410775. Retrospectively registered on 30 June 2019.

Prolonged non-weightbearing treatment decreases femoral head deformity compared to symptomatic treatment in the initial stage of Legg-Calvé-Perthes disease.

The purpose of this study is to investigate the potential benefit of using prolonged non-weightbearing (PNWB) as a treatment option for early-stage Legg-Calvé-Perthes disease (LCPD). An Institutional Review Board (IRB) approved this retrospective study of patients with LCPD and ≥2-year follow-up. Patients 6-12 years of age were included if treatment began in Waldenstrom stage 1 or 2A. PNWB consisted of ≥6 months of non- or toe-touch weightbearing. PNWB was recommended if perfusion MRI demonstrated ≥40% hypoperfusion of the femoral head and parents decided against operative treatment. The control group consisted of symptomatically treated patients. Deformity index and epiphyseal quotient were measured at 2-year follow-up. Stulberg classification and sphericity deviation score (SDS) were determined at skeletal maturity or at a minimum of 5-year follow-up. When treatment was initiated in Waldenstrom stage 1, the PNWB group had significantly less femoral head deformity, including deformity index (0.21 vs. 0.52; P < 0.001), epiphyseal quotient (69% vs. 43%; P < 0.001), SDS (18 vs. 52; P = 0.004), and Stulberg (50% good vs. 0% good; P = 0.044). The PNWB group mean hypoperfusion was 68%, indicating severe hypoperfusion. Duration of recommended non-weight bearing in the PNWB group was 11.5 months (range 7-17 months). Despite severe femoral head hypoperfusion, PNWB begun during the initial stage of LCPD decreased femoral head deformity. PNWB should be considered a treatment option for patients/parents who do not wish to pursue operative intervention in early-stage LCPD with substantial hypoperfusion. Level of Evidence III - retrospective comparative study.

Optimal management of older people with frailty non-weight bearing after lower limb fracture: a scoping review.

BackgroundPatients with lower limb fractures who are non-weight bearing are at risk of the complications of the associated immobility and disability, particularly people with frailty, but there is lack of clarity about what constitutes optimal care for such patients. A scoping literature review was conducted to explore what evidence is available for the management of this patient group.MethodsMEDLINE (PubMed) CINAHL, EMBASE and the Cochrane databases of published literature and the HMIC and SIGLE sites for grey literature were searched for primary research studies and expert reports, using an iterative approach initially including the key term ‘non-weight bearing’. All study types were included. Analysis was by narrative synthesis.ResultsNo papers were identified from a search using the key phrase ‘non-weight bearing’. With this term removed, 11 indirectly relevant articles on lower limb fractures were retrieved from the searches of the electronic databases comprising three observational studies, five non-systematic review articles, a systematic review, an opinion piece and a survey of expert opinion that had relevance to restricted weight bearing patients. The observational studies indicated depression, cognition and nutrition affect outcome and hence have indirect relevance to management. The non-systematic reviews articles emphasised the importance of maintaining strength and range of movement during immobilisation and advised an orthogeriatric model of care. Fourteen UK and 97 non-UK guidelines relevant to fragility fractures, falls and osteoporosis management were found in the grey literature, but none made specific recommendations regarding the management of any period of non-weight bearing.DiscussionThese findings provide a summary of the evidence base that can be used in the development of a clinical guideline for these patients but is not sufficient. We propose that, a guideline should be developed for these patients using an expert consensus process.

Primary Hyperparathyroidism From Ectopic Parathyroid Adenoma in a Patient With Bilateral Slipped Capital Femoral Epiphysis

Background: Primary hyperparathyroidism has been reported in 13 pediatric patients presenting with slipped capital femoral epiphysis (SCFE), but never in patients with ectopic parathyroid adenoma [1]. Case report: A 12-year-old boy with obesity (BMI 99th percentile) and autism spectrum disorder presented with a limp and was found to have bilateral SCFE. Calcium was elevated to 12.3 mg/dL (reference range 8.0–10.5) with phosphorus of 3.2 mg/dL (3.0–5.7), alkaline phosphatase 775 units/L (40–360), tubular reabsorption of phosphorus 89% (> 95%), 25OH-vitamin D 12.1 ng/mL (30–80), 1,25OH-vitamin D 246.6 pg/mL (19.9–79.3), and PTH 1191 pg/mL (10–65). He had significant neuropsychiatric agitation but denied constipation, polyuria, and other symptoms of hypercalcemia. He had in situ pinning of the SCFE bilaterally and was hyperhydrated with minimal improvement in his calcium level. Neck ultrasound revealed no parathyroid adenoma. He was discharged on cholecalciferol 1000 IU daily with plans for outpatient Tc-99m Sestamibi scintigraphy. Following discharge, he developed significant nausea, did not tolerate the cholecalciferol, and was non-weight bearing. Repeat labs and imaging 5 days later demonstrated calcium had risen to 16.7 mg/dL with phosphorus of 2.2 mg/dL. He was admitted and calcium improved transiently to less than 12 mg/dL with intranasal calcitonin therapy. Sestamibi and subsequent CT scan revealed a 2.7x1.6x1.9 cm ectopic parathyroid adenoma in the upper anterior mediastinum. He had thoracoscopic resection of the mass, which was revealed to be intrathymic, and PTH levels fell from 1613 pg/mL pre-operatively to 76 pg/mL 30 minutes post-resection. Post-operatively, he developed hungry bone syndrome with a calcium nadir of 7.6 mg/dL and phosphorus nadir of 1.6 mg/dL, which required oral calcium and calcitriol for 10 days. With normalization of his calcium, his neuropsychiatric symptoms improved. Pathology revealed a parathyroid adenoma. Conclusion: Primary hyperparathyroidism can be associated with SCFE and should be considered even in patients with traditional risk factors for SCFE, especially with bilateral disease. Pediatric patients with primary hyperparathyroidism and negative neck imaging should be further evaluated for ectopic parathyroid adenomas.

The Single Leg Squat Test: A "Top-Down" or "Bottom-Up" Functional Performance Test?

BackgroundMedial knee deviation (MKD) during the single leg squat test (SLST) is a common clinical finding that is often attributed to impairments of proximal muscular structures. Investigations into the relationship between MKD and the foot and ankle complex have provided conflicting results, which may impact clinicians’ interpretation of the SLST.PurposeThe purpose of this study was to compare ankle dorsiflexion range of motion (ROM) and foot posture in subjects that perform the SLST with MKD (fail) versus without MKD (pass).HypothesisThere will be a difference in ankle dorsiflexion ROM and/or foot posture between healthy individuals that pass and fail the SLST for MKD.Study DesignCross-sectional study.MethodsSixty-five healthy, active volunteers (sex = 50 female, 15 male; age = 25.2 +/- 5.6 years; height = 1.7 +/- .1 m; weight = 68.5 +/- 13.5 kg) who demonstrated static balance and hip abductor strength sufficient for performance of the SLST participated in the study. Subjects were divided into pass and fail groups based on visual observation of MKD during the SLST. Foot Posture Index (FPI-6) scores and measures of non-weight bearing and weight bearing active ankle dorsiflexion (ROM) were compared.ResultsThere were 33 individuals in the pass group and 32 in the fail group. The groups were similar on age (p = .899), sex (p = .341), BMI (p = .818), and Tegner Activity Scale score (p = .456). There were no statistically significant differences between the groups on the FPI-6 (pass group mean = 2.5 +/- 3.9; fail group mean = 2.3 +/- 3.5; p = .599), or any of the measures of dorsiflexion range of motion (non-weight bearing dorsiflexion with knee extended: pass group = 6.9o +/- 3.7o, fail group = 7.8o +/- 3.0o; non-weight bearing dorsiflexion with knee flexed: pass group = 13.5o +/- 5.6o, fail group = 13.9o +/- 5.3o; weight bearing dorsiflexion: pass group = 42.7o +/- 6.0o, 42.7o +/- 8.3o, p = .611).ConclusionsFailure on the SLST is not related to differences in clinical measures of active dorsiflexion ROM or foot posture in young, healthy individuals. These findings suggest that clinicians may continue using the SLST to assess neuromuscular performance of the trunk, hip, and knee without ankle dorsiflexion ROM or foot posture contributing to results.Level of EvidenceLevel 3.