Postoperative Weight-bearing Restrictions Research Articles

Immediate Weight-bearing Through Walker or Crutches After Surgical Fixation of Clavicle Fractures in Patients With Lower Extremity Fractures: A Retrospective Cohort Study.

To assess the safety of immediate upper extremity weight-bearing as tolerated (WBAT) rehabilitation protocol after clavicle fracture open reduction internal fixation (ORIF). Retrospective cohort study. Three Level 1 trauma centers. Patients older than 18 years who had ORIF of mid-shaft clavicle fractures and lower extremity fractures who were allowed immediate WBAT on their affected upper extremity through use of a walker or crutches were included. All clavicles were fixed with either precontoured clavicular plates or locking compression plates. Included patients were those who had clinical/radiographic follow-up until fracture union, nonunion, or construct failure. WBAT patients were matched in a one-to-one fashion to a cohort with isolated clavicle fractures who were treated non-weight-bearing (NWB) postoperatively on their affected upper extremity. Matching was done based on age, sex, and temporality of fixation. After matching, treatment and control groups were compared to determine differences in possible confounding variables that could influence the primary outcome, including patient demographics, fracture classification, cortices of fixation, and construct type. All patients were assessed to verify conformity with weight-bearing recommendation. Primary outcome was early hardware failure (HWF) with or without revision surgery. Secondary outcomes included postoperative infections and union of fracture. Thirty-nine patients were included in the WBAT cohort; there were no significant differences with the matched NWB cohort based on patient demographics. Both the WBAT and the NWB cohorts had 2.5% chance of acute HWF that required surgical intervention ( P = 1.0). Additionally, there was no difference in overall HWF ( P = 0.49). All patients despite weight-bearing status including those who required revision ORIF for acute HWF had union of their fracture ( P = 1.0). Our data would support that immediate weight-bearing after clavicle fracture fixation in patients with concomitant lower extremity trauma does not lead to an increase in HWF or impact ultimate union. This challenges the dogma of prolonged postoperative weight-bearing restrictions and allow for earlier rehabilitation. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Postoperative weight-bearing restrictions andrehabilitation protocols after hip arthroscopy forfemoroacetabular impingement: a systematic review.

Despite recent increased interest in hip arthroscopy for the management of femoroacetabular impingement (FAI), there is little evidence to guide weight-bearing recommendations and rehabilitation postoperatively. The primary objective of this study was to determine if sufficient evidence exists to recommend specific weight-bearing restrictions postoperatively. This study was registered with PROSPERO (CRD42021247741). PubMed, MEDLINE and Embase were searched on 3 March 2023 for Level I-IV studies including patients over the age of 18 years, with a minimum 1-year follow-up and reporting of a weight-bearing status, a patient-reported outcome measure (PROM) and a clinical outcome. Meta-analysis was precluded due to heterogeneity in the included studies, and a descriptive analysis was undertaken. Methodological quality and risk of bias were assessed with the methodological index for non-randomized studies (MINORS). Twenty-four studies including 2231 patients who underwent hip arthroscopy for treatment of FAI were included (follow-up interval 33.2 ± 24.7 months). Most articles (62.5%) were case series. There were seven terms describing weight-bearing recommendations, with 83% being some variation of 'partial weight-bearing'. Eight PROMs were reported, with 83% using the modified Harris Hip Score and 87.5% of studies reporting reoperation rates. Only 75% of studies reported rehabilitation protocols. The average MINORS score was 11.07 ± 1.10 out of 16 for non-comparative studies and 18.22 ± 1.48 out of 24 for comparative studies. The reporting of weight-bearing status, clinical outcomes, PROMs and rehabilitation parameters remains poor. At present, sufficient comparative evidence does not exist to make specific weight-bearing recommendation postoperatively.

The Fragility Fracture Postoperative Mobilisation multicentre audit : the reality of weightbearing practices following operations for lower limb fragility fractures.

The purpose of this study was to determine the weightbearing practice of operatively managed fragility fractures in the setting of publically funded health services in the UK and Ireland. The Fragility Fracture Postoperative Mobilisation (FFPOM) multicentre audit included all patients aged 60 years and older undergoing surgery for a fragility fracture of the lower limb between 1 January 2019 and 30 June 2019, and 1 February 2021 and 14 March 2021. Fractures arising from high-energy transfer trauma, patients with multiple injuries, and those associated with metastatic deposits or infection were excluded. We analyzed this patient cohort to determine adherence to the British Orthopaedic Association Standard, "all surgery in the frail patient should be performed to allow full weight-bearing for activities required for daily living". A total of 19,557 patients (mean age 82 years (SD 9), 16,241 having a hip fracture) were included. Overall, 16,614 patients (85.0%) were instructed to perform weightbearing where required for daily living immediately postoperatively (15,543 (95.7%) hip fracture and 1,071 (32.3%) non-hip fracture patients). The median length of stay was 12.2 days (interquartile range (IQR) 7.9 to 20.0) (12.6 days (IQR 8.2 to 20.4) for hip fracture and 10.3 days (IQR 5.5 to 18.7) for non-hip fracture patients). Non-hip fracture patients experienced more postoperative weightbearing restrictions, although they had a shorter hospital stay. Patients sustaining fractures of the shaft and distal femur had a longer median length of stay than demographically similar patients who received hip fracture surgery. We have shown a significant disparity in weightbearing restrictions placed on patients with fragility fractures, despite the publication of a national guideline. Surgeons intentionally restrict postoperative weightbearing in the majority of non-hip fractures, yet are content with unrestricted weightbearing following operations for hip fractures. Cite this article: Bone Joint J2022;104-B(8):972-979.

Acetabular defect management and revision arthroplasty via the direct anterior approach.

Acetabular revision arthroplasty and osseous defect management through the direct anterior approach (DAA) with or without proximal extension. Aseptic or septic component loosening, periacetabular osseous defects, pelvic discontinuity, intrapelvic cup protrusion, anterior pseudotumors, iliopsoas tendonitis, polyethylene wear or iliopsoas abscess. Clinically relevant gluteal tendon lesions, active infection, morbid obesity, large abdominal pannus, ASA (American Society of Anesthesiologists) score > III, inguinal skin infection. Electrocautery dissection is recommended to dissect the Hueter interval and to debulk pericapsular scar tissue. At all times during capsular debulking, it should be made sure not to damage the iliopsoas tendon or the neurovascular bundle. Astepwise releasing sequence can facilitate dislocation of the prosthesis. Most cases can be revised via the standard DAA but certain circumstances require an intra- or extrapelvic extension. Access to the anterior gluteal surface of the ilium can be provided using a"tensor snip". More posterior access is provided by the extensile extrapelvic approach described by Smith-Petersen. The intrapelvic Levine extension offers access to the entire visceral surface of the ilium and large parts of the anterior column. Patient revised via the intra- or extrapelvic extension and patients suffering from extensive soft tissue or osseous defects should undergo postoperative weight-bearing restrictions with 20 kg for 6weeks. Based on our studies, there is no limitation on the type of acetabular implant that can be used in DAA revision arthroplasty. Moreover, virtually all types of periacetabular osseous defects can be managed through the approach and its extensions. Acetabular revision arthroplasty via the DAA and its extensions is safe and can result in good midterm results.

Plate fixation of the anterior pelvic ring in patients with fragility fractures of the pelvis

IntroductionIn fragility fractures of the pelvis (FFP), fractures of the posterior pelvic ring are nearly always combined with fractures of the anterior pelvic ring. When a surgical stabilization of the posterior pelvis is performed, a stabilization of the anterior pelvis is recommended as well. In this study, we aim at finding out whether conventional plate osteosynthesis is a valid option in patients with osteoporotic bone.Materials and methodsWe retrospectively reviewed medical charts and radiographs of all patients with a FFP, who underwent a plate osteosynthesis of the anterior pelvic ring between 2009 and 2019. Patient demographics, fracture characteristics, properties of the osteosynthesis, complications and revision surgeries were documented. Single plate osteosynthesis (SPO) at the pelvic brim was compared with double plate osteosynthesis (DPO) with one plate at the pelvic brim and one plate anteriorly. We hypothesized that the number and severity of screw loosening (SL) or plate breakage in DPO are lower than in SPO.Results48 patients with a mean age of 76.8 years were reviewed. In 37 cases, SPO was performed, in 11 cases DPO. Eight out of 11 DPO were performed in patients with FFP type III or FFP type IV. We performed significantly more DPO when the instability was located at the level of the pubic symphysis (p = 0.025). More patients with a chronic FFP (surgery more than one month after diagnosis) were treated with DPO (p = 0.07). Infra-acetabular screws were more often inserted in DPO (p = 0.056). Screw loosening (SL) was seen in the superior plate in 45% of patients. There was no SL in the anterior plate. There was SL in 19 of 37 patients with SPO and in 3 of 11 patients with DPO (p = 0.16). SL was localized near to the pubic symphysis in 19 of 22 patients after SPO and in all three patients after DPO. There was no SL in DPO within the first month postoperatively. We performed revision osteosynthesis in six patients (6/48), all belonged to the SPO group (6/37). The presence of a bone defect, unilateral or bilateral anterior pelvic ring fracture, post-operative weight-bearing restrictions, osteosynthesis of the posterior pelvic ring, and the presence of infra- or supra-acetabular screws did not significantly influence screw loosening in SPO or DPO.ConclusionThere is a high rate of SL in plate fixation of the anterior pelvic ring in FFP. In the vast majority, SL is located near to the pubic symphysis. DPO is associated with a lower rate of SL, less severe SL and a later onset of SL. Revision surgery is less likely in DPO. In FFP, we recommend DPO instead of SPO for fixation of fractures of the anterior pelvic ring, which are located in or near to the pubic symphysis.

Cupule sans ciment de révision pour arthroplastie primaire pour fracture de l’acetabulum chez des patients gériatriques ostéoporotiques

BackgroundElderly patients suffering from hip fractures are usually not able to fulfill postoperative weight-bearing restrictions. Therefore, the operative fixation construct has to be as stable as possible. Aim of the present study was to determine: (1) whether a therapeutic advantage could be achieved when using hip arthroplasty to treat acetabular fractures in geriatric patients; (2) whether an acetabular revision cup would be suitable for achieving fast postoperative mobilization and full weight-bearing; and (3) when a treatment with an uncemented hip revision cup for the primary fixation of osteoporotic acetabular fractures in geriatric patients is indicated. Materials and methodsThe functional outcome of THA using a reconstruction cup for an acetabular fracture was evaluated in ten patients using standardized scoring instruments. In addition, an analysis of the preexisting literature referring to total hip replacement in geriatric acetabular fractures was conducted and an algorithm for standardizing the treatment approach for geriatric patients with acetabular fractures was developed. ResultsThe mean EQ-5D-3L quality of life score 0.7. The mean VAS score was 58.2. The average Barthel Index was 80.0 points [range: 0–100]. The mean HHS was 72.0 points, while the MHH Score yielded an average of 63.4 points. The average AP Score was 7.5. The literature analysis showed that total hip arthroplasty could be a feasible option for geriatric acetabular fractures. ConclusionPrimary hip arthroplasty using uncemented revision cup fixed with angular stable screws showed good results and is a feasible treatment option of acetabular fractures in geriatric patients. The approach is especially beneficial in patients with poor bone stock and allows postoperative full weight-bearing. The presented treatment algorithm could be a useful tool for identifying the most appropriate treatment option. Level of evidenceIIb.

Cementless hip revision cup for the primary fixation of osteoporotic acetabular fractures in geriatric patients

BackgroundElderly patients suffering from hip fractures are usually not able to fulfil postoperative weight-bearing restrictions. Therefore, the operative fixation construct has to be as stable as possible. Aim of the present study was to determine (1) whether a therapeutic advantage could be achieved when using hip arthroplasty to treat acetabular fractures in geriatric patients; (2) whether an acetabular revision cup would be suitable for achieving fast postoperative mobilization and full weight-bearing; and (3) when a treatment with an uncemented hip revision cup for the primary fixation of osteoporotic acetabular fractures in geriatric patients is indicated. Materials and methodsThe functional outcome of THA using a reconstruction cup for an acetabular fracture was evaluated in ten patients using standardized scoring instruments. In addition, an analysis of the preexisting literature referring to total hip replacement in geriatric acetabular fractures was conducted and an algorithm for standardizing the treatment approach for geriatric patients with acetabular fractures was developed. ResultsThe mean EQ-5D-3L quality of life score 0.7. The mean VAS Score was 58.2. The average Barthel Index was 80.0 points [range: 0–100]. The mean HHS was 72.0 points, while the MHH Score yielded an average of 63.4 points. The average AP Score was 7.5. The literature analysis showed that total hip arthroplasty could be a feasible option for geriatric acetabular fractures. ConclusionPrimary hip arthroplasty using uncemented revision cup fixed with angular stable screws showed good results and is a feasible treatment option of acetabular fractures in geriatric patients. The approach is especially beneficial in patients with poor bone stock and allows postoperative full weight-bearing. The presented treatment algorithm could be a useful tool for identifying the most appropriate treatment option. Level of evidenceIIb.

Supplemental cerclage wiring in angle stable plate fixation of distal tibial spiral fractures enables immediate post-operative full weight-bearing: a biomechanical analysis

PurposeDistal tibial fractures generally require post-operative weight-bearing restrictions. Especially geriatric patients are unable to follow these recommendations. To increase post-operative implant stability and enable early weight-bearing, augmentation of the primary osteosynthesis by cerclage is desirable. The purpose of this study was to identify the stabilizing effects of a supplemental cable cerclage following plate fixation of distal tibial spiral fractures compared to solitary plate osteosynthesis.MethodsIn eight synthetic tibiae, a reproducible spiral fracture (AO/OTA 42-A1.1c) was stabilized by angle stable plate fixation. Each specimen was statically loaded under combined axial and torsional loads to simulate partial (200 N, 2 Nm) and full (750 N, 7 Nm) weight-bearing. Tests were repeated with supplemental cable cerclage looped around the fracture zone. In a subsequent stepwise increased dynamic load scenario, construct stiffness and interfragmentary movements were analyzed.ResultsWith supplemental cable cerclage, construct stiffness almost tripled compared to solitary plate osteosynthesis (2882 ± 739 N/mm vs. 983 ± 355 N/mm; p < 0.001). Under full weight-bearing static loads, a supplemental cerclage revealed reduced axial (− 55%; p = 0.001) and shear movement (− 83%; p < 0.001), and also lowered shear movement (− 42%; p = 0.001) compared to a solitary plate under partial weight-bearing. Under dynamic loads supplemental cerclage significantly reduced axial (p = 0.005) as well as shear movements (p < 0.001).ConclusionSupplemental cable cerclage significantly increases fixation stiffness and reduces shear movement in distal tibial spiral fractures. This stabilizing effect enables from a biomechanical point of view immediate mobilization without any weight-bearing restrictions, which may improve the quality of care of orthopedic patients and may trigger a change towards early weight-bearing regimes, especially geriatric patients would benefit from.

Intraoperative Proximal Tibia Periprosthetic Fractures in Primary Total Knee Arthroplasty.

Intraoperative fracture of the proximal tibia is a rare complication of total knee arthroplasty (TKA) with few studies available reporting risk factors or prognosis. A review of our prospective joint registry was performed to determine the incidence and associated risk factors of intraoperative tibia fractures during primary TKA; 14,966 TKAs of all manufacturers were performed with 9 intraoperative tibia fractures. All fractures occurred in a single TKA design. There were 8,155 TKAs of this design performed with a fracture incidence of 0.110%. All but one fracture occurred on the medial tibial plateau, and all but one occurred during preparation of the tibia with keel punching. A control group of 75 patients (80 knees) with the same TKA design were randomly selected. Baseplates size 3 or smaller were less likely to experience an intraoperative fracture (odds ratio [OR]: 0.864, 95% confidence interval [CI]: 0.785-0.951), as were knees with a polyethylene insert thickness of 13 mm or larger (OR: 0.882, 95% CI: 0.812-0.957). Fractures were treated with a variety of different methods, but every patient had at least one screw placed and most (67%) had postoperative weight-bearing restrictions. At final follow-up, there were no cases of nonunion, component subsidence, or need for reoperation. Intraoperative tibia fractures are a rare complication of this TKA design at 0.11%. Knees with baseplates of size ≤3 and polyethylene thickness ≥13 mm were less likely to experience intraoperative fracture. These findings may be related to the depth of tibial resection, requiring the use of a thicker polyethylene insert, and a change in the keel width in implants size 4 or larger. No fracture patients required reoperation.

Weight-bearing restrictions reduce postoperative mobility in elderly hip fracture patients

Reduced mobility is a severe threat to the clinical outcomes and survival of elderly hip fracture patients. These patients generally struggle to comply with partial weight bearing, yet postoperative weight-bearing restrictions are still recommended by nearly 25% of surgeons. Therefore, we hypothesized that weight-bearing restrictions in elderly hip fracture patients merely leads to reduced mobility, while transposing full weight to the fractured extremity remains unaffected disregarding the prescribed aftercare. 41 equally treated patients with pertrochanteric fractures were enrolled consecutively in a maximum care hospital in a pre-post study design (level of evidence 2). A study group of 19 patients was instructed to maintain partial weight bearing (PWB), whereas the control group of 22 patients was instructed to mobilize at full weight bearing (FWB). All patients were asked to participate in a gait analysis using an insole force sensor (loadsol®, Novel, Munich, Germany) on the fifth postoperative day. The postoperative Parker Mobility Score in the PWB group compared to the FWB group was significantly reduced (3.21 vs. 4.73, p < 0.001). Accordingly, a significantly lower gait speed in the PWB group of 0.16m/s vs. 0.28m/s was seen (p = 0.003). No difference in weight bearing was observed in between the groups (average peak force 350.25N vs. 353.08N, p = 0.918), nor any differences in the demographic characteristics, ASA Score, Barthel Index or EQ5D. Weight-bearing restrictions in elderly hip fracture patients contributed to a loss of mobility, while no significant differences in loading of the affected extremity were observed. Therefore, postoperative weight-bearing restrictions in elderly hip fracture patients should be avoided, to achieve early mobilization at full weight bearing.

Increased 30-Day Complications in Geriatric Hip-Fracture Patients with Postoperative Weight-Bearing Restrictions: An American College of Surgeons NSQIP Analysis of 4,918 Patients

Increased 30-Day Complications in Geriatric Hip-Fracture Patients with Postoperative Weight-Bearing Restrictions: An American College of Surgeons NSQIP Analysis of 4,918 Patients

Increased complications in geriatric patients with a fracture of the hip whose postoperative weight-bearing is restricted: an analysis of 4918 patients.

The aims of this study were to evaluate the incidence of postoperatively restricted weight-bearing and its association with outcome in patients who undergo surgery for a fracture of the hip. Patient aged > 60 years undergoing surgery for a hip fracture were identified in the 2016 National Surgical Quality Improvement Program (NSQIP) Hip Fracture Targeted Procedure Dataset. Analysis of the effect of restricted weight-bearing on adverse events, delirium, infection, transfusion, length of stay, return to the operating theatre, readmission and mortality within 30 days postoperatively were assessed. Multivariate regression analysis was used to adjust for confounding demographic, comorbid and procedural characteristics. Of the 4918 patients who met inclusion criteria, 3668 (63.53%) were allowed to weight-bear as tolerated postoperatively. Controlling for patient and procedural factors, multivariate odds of any adverse event, major adverse event, delirium, infection, transfusion, length of stay ≥ 75th percentile (six days) and mortality within 30 days were all higher in patients with weight-bearing restrictions. Notably, there were no differences for thromboembolic events, return to the operating theatre or readmission within 30 days between the groups. Elderly patients with a fracture of the hip with postoperative weight-bearing restrictions have a significantly greater risk of developing most adverse events compared with those who are encouraged to weight-bear as tolerated. These findings emphasize the importance of immediate weight-bearing as tolerated to optimize the outcome in these frail patients; however nearly 25% of surgeons fail to meet this evidence-based guideline. Cite this article: Bone Joint J 2018;100-B:1377-84.

Inability of Older Adult Patients with Hip Fracture to Maintain Postoperative Weight-Bearing Restrictions.

For elderly trauma patients, a basic goal is early mobilization, as immobilization can trigger various complications, such as venous thromboembolism, pneumonia, urinary tract infections, and pressure ulcers. Although partial weight-bearing has been shown to significantly increase mortality compared with unrestricted weight-bearing, it remains a frequent recommendation of aftercare following lower-extremity fracture fixation. An insole force sensor was used to measure true postoperative weight-bearing by patients ≥75 years of age treated for hip fracture compared with patients 18 to 40 years of age treated for ankle fracture. Both groups were instructed to maintain partial weight-bearing on the affected limb (≤20 kg) postoperatively. Following standardized physiotherapy training, gait analysis was performed. None of the patients in the elderly test group were able to comply with the weight-bearing restriction as recommended. We found that 69% (11 of 16) of the patients exceeded the specified load by more than twofold, whereas significantly more patients in the younger control group (>75% [14 of 18]) achieved almost the entire weight-bearing restriction (p < 0.001). Only 1 of the elderly patients was able to comply with the predetermined weight-bearing restriction, and only for a short period of time. In comparison, significantly more patients in the control group (89% [16 of 18]; p < 0.001) maintained the partial load for nearly the entire time during gait analysis. Elderly patients seem to be unable to maintain weight-bearing restrictions. As early mobilization of geriatric trauma patients is an important element for a successful rehabilitation, the directive of postoperative partial weight-bearing for these patients should be abandoned. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Rehabilitation and Postoperative Management Practices After Osteochondral Allograft Transplants to the Distal Femur: A Report From the Metrics of Osteochondral Allografts (MOCA) Study Group 2016 Survey.

Context:We present the current spectrum of postoperative management practices for patients receiving distal femur osteochondral allograft (OCA) transplants.Evidence Acquisition:The Joint Restoration Foundation database was examined in cooperation with the Metrics of Osteochondral Allografts study group to identify 121 surgeons who had performed at least 1 OCA transplant in the past year; 63% of surgeons responded.Study Design:Clinical survey.Level of Evidence:Level 3.Results:Postoperative weightbearing restrictions ranged from immediate nonweightbearing with full weightbearing by 12 weeks to immediate weightbearing as tolerated. Most surgeons who performed fewer (<10) OCA transplants per year followed the most restrictive protocol, while surgeons who performed more (>20) OCA transplants per year followed the least restrictive protocol. One-third of surgeons with the most restrictive protocol were more likely to change their protocol to be less restrictive over time, while none of those with the least restrictive protocol changed their protocol over time. Fifty-five percent of surgeons permitted return to full activity at 26 weeks, while 27% of surgeons lifted restrictions at 16 weeks.Conclusion:Characterization of the spectrum of postoperative management practices after OCA transplantation provides a foundation for future investigations regarding patient outcomes and associated cost to establish best practice guidelines. Fundamentally, surgeons with more experience with this procedure tended to be more aggressive with their postoperative rehabilitation guidelines. Most commonly, rehabilitation provided for some degree of limited weightbearing; however, the spectrum also included immediate full weightbearing practices.

Primary prosthetic replacement in per- and intertrochanteric fractures.

Hip arthroplasty is rarely indicated in the treatment of per- and intertrochanteric femur fractures. Although the majority of fractures are amenable to closed- or open reduction and internal fixation (CRIF/ORIF), in some patients the complexity of the fracture or other patient-related factors may cause the orthopaedic surgeon to consider arthroplasty as the treatment of choice. Decision-making is challenging, and a reliable score has not yet been established. Reviewing literature, several predictors of inferior outcome after CRIF/ORIF in per- and intertrochanteric fractures such as age, gender, poor bone quality, hip osteoarthritis, operation time and postoperative weight-bearing restrictions have been identified. Based on the literature review, a novel Hamburg Per- and Intertrochanteric Fracture Score (HPIFS) is proposed to support decision-making for per- and intertrochanteric fracture treatment. CRIF/ORIF remain the workhorses in per- and intertrochanteric fracture management. Arthroplasty offers an advantageous treatment option for a well-defined patient and fracture collective. The HPIFS might support the decision-making process.

Driving After Orthopedic Surgery

As a result of reading this article, physicians should be able to: (1) Identify preoperative factors that may contribute to a patient's ability to return to driving after orthopedic surgery. (2) Understand the role of upper-extremity immobilization and how it may impair a patient's ability to operate a motor vehicle. (3) Recognize how various forms of lower-extremity immobilization (e.g., controlled ankle-motion boot, cast, and Aircast Walker) affect braking reaction times and total braking times. (4) Be aware of current guidelines about when it is appropriate to return to driving following arthroscopy, lower-extremity fracture, and hip and knee arthroplasty. Few guidelines are available to assist orthopedic surgeons in advising patients about when to return to driving after orthopedic surgery. A patient's surgical procedure, postoperative weight-bearing restrictions, immobilization, and other factors influence a patient's ability to drive after orthopedic surgery. Multiple studies have used driving simulators to predict when it may be safe to return to driving after orthopedic surgery. However, study conclusions and recommendations vary significantly. This article reviews the factors contributing to a patient's ability to return to driving after orthopedic surgery and reviews recommendations based on the available literature following fracture, arthroscopy, and arthroplasty.

The Modified Lapidus Procedure for Hallux Valgus: A Clinical and Radiographic Analysis

Historically, the modified Lapidus procedure has been considered technically challenging, with high rates of complications, including nonunion and malunion. The purpose of this study was to review the clinical and radiographic results of this technique for the treatment of hallux valgus associated with first ray hypermobility, specifically examining patient satisfaction and the incidence of complications. We retrospectively reviewed the results of the modified Lapidus procedure in 32 patients (38 feet). Evaluation included preoperative and postoperative questionnaires, physical examination, and radiographs. Complete clinical data was available for 29 patients (35 feet) and complete radiographic data for 29 patients (34 feet). Average age at surgery was 54 (range 27 to 84) years. Average followup was 42 months (range 29 to 93) months. Average preoperative visual analog pain score was 7.2 and postoperative 2.3 (p < 0.001). Average preoperative AOFAS Hallux MTP-IP Score was 44.8 and postoperative 87.3 (p < 0.001). Average preoperative intermetatarsal (IM) angle was 16 degrees, and the hallux valgus (HV) angle was 34 degrees. Postoperatively, the average IM angle was 6 degrees, the HV angle 11 degrees. There were no cases of nonunion or malunion. Complications included symptomatic hallux varus in two, recurrence of hallux valgus deformity in one, deep venous thrombosis in one, and failure of fixation in one patient. Twenty-four percent of patients (7 of 29) noted the subjective sensation of midfoot stiffness and 34% (10 of 29) noted forefoot stiffness. None of these patients thought that the stiffness was a disability. Ninety percent of patients (26 of 29) were satisfied with their foot function, and 86% (25 of 29) were satisfied with the cosmetic appearance of their foot. The modified Lapidus procedure results in a satisfactory clinical outcome in most patients. With meticulous operative technique, rigid internal fixation, and strict postoperative weightbearing restrictions, successful union can be achieved and complications can be minimized. Care should be taken to avoid hallux varus, and patients need to be counseled regarding a potentially long convalescent period and possible postoperative stiffness.