Postoperative Weight-bearing Status Research Articles

No Difference in Acute Outcomes for Patients Undergoing Fix and Replace Versus Fixation Alone in the Treatment of Geriatric Acetabular Fractures.

To compare acute outcomes between patients undergoing fix and replace (FaR) versus open-reduction and internal fixation (ORIF) alone in the treatment of geriatric acetabular fractures. Retrospective Cohort Study. Single Level 2 Trauma Center. Consecutive acetabular fracture patients ≥ 55 years of age treated by two orthopaedic trauma surgeons at one tertiary care center from January 2017 to April 2022 with FaR versus ORIF were identified. Included were those with complete datasets within the 180-day global period. Excluded were patients with previous ORIF of the acetabulum or femur, or revision total hip arthroplasty. The primary outcomes were length of hospital stay (LOS), postoperative weight-bearing status, postoperative disposition, time to postoperative mobilization, and 90-day readmission rates. Secondary outcomes compared included demographic information, injury mechanism, surgical time, complications, revisions, and preoperative and postoperative Hip Disability and Osteoarthritis Outcomes Score for Joint Replacement (HOOS Jr.) scores. These were compared between FaR and ORIF groups. Seventeen FaR patients (average age 74.5 ± 9.0 years) and 11 ORIF patients (average age 69.4 ± 9.6 years) met inclusion criteria. Mean follow-up was 26.4 months (range: 6-75.6 months). More FaR group patients were ordered immediate weight-bearing as tolerated or partial weight-bearing compared with ORIF alone (70% vs. 9.0%, P = 0.03). More patients in the FaR group had pre-existing hip osteoarthritis compared with ORIF alone (71% vs. 27%, P = 0.05). Fracture classification ( P = 0.03) and Charlson Comorbidity Index ( P = 0.02) differed between the 2 groups. There were no other differences in demographics, LOS ( P = 0.99), postoperative disposition ( P = 0.54), time to postoperative mobilization ( P = 0.38), 90-day readmission rates ( P = 0.51), operative time ( P = 0.06), radiographic union ( P = 0.35), time to union ( P = 0.63), pre- ( P = 0.32) or postoperative HOOS Jr. scores ( P = 0.80), delta HOOS Jr. scores ( P = 0.28), or reoperation rates between groups ( P = 0.15). FaR and ORIF seem to be sound treatment options in the management of geriatric acetabular fractures. Patients in the FaR group achieved immediate or partial weight-bearing earlier than the ORIF group; however, time to postoperative mobilization did not differ between the two groups. The remainder of acute postoperative outcomes (LOS, postoperative disposition, and 90-day readmission rates) did not differ between the two groups. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Fix or Replace? Patient Preferences for the Treatment of Geriatric Lower Extremity Fractures: A Discrete Choice Experiment.

When considering treatment options for geriatric patients with lower extremity fractures, little is known about which outcomes are prioritized by patients. This study aimed to determine the patient preferences for outcomes after a geriatric lower extremity fracture. We administered a discrete choice experiment survey to 150 patients who were at least 60years of age and treated for a lower extremity fracture at a Level I trauma center. The discrete choice experiment presented study participants with 8 sets of hypothetical outcome comparisons, including joint preservation (yes or no), risk of reoperation at 6 months and 24months, postoperative weightbearing status, disposition, and function as measured by return to baseline walking distance. We estimated the relative importance of these potential outcomes using multinomial logit modeling. The strongest patient preference was for maintained function after treatment (59%, P < .001), followed by reoperation within 6months (12%, P < .001). Although patients generally favored joint preservation, patients were willing to change their preference in favor of joint replacement if it increased function (walking distance) by 13% (SE, 66%). Reducing the short-term reoperation risk (12%, P < .001) was more important to patients than reducing long-term reoperation risk (4%, P = .33). Disposition and weightbearing status were lesser priorities to patients (9%, P < .001 and 7%, P < .001, respectively). After a lower extremity fracture, geriatric patients prioritized maintained walking function. Avoiding short-term reoperation was more important than avoiding long-term reoperation. Joint preservation through fracture fixation was the preferred treatment of geriatric patients unless arthroplasty or arthrodesis provides a meaningful functional benefit. Hospital disposition and postoperative weightbearing status were less important to patients than the other included outcomes. Geriatric patients strongly prioritize function over other outcomes after a lower extremity fracture.

Best of Both Worlds? Fixation of Distal Femur Fractures with the Nail-Plate Construct.

Distal femoral fractures are a significant injury sustained by low- and high-energy trauma. Common treatment practices are lateral locking plate or intramedullary nail fixation, with disadvantages including risk of non and malunion and limited post-operative weightbearing status. Combining both techniques as a nail-plate construct (NPC) theoretically achieves enhanced fixation to allow immediate weightbearing. The aim of this study is to examine radiographic union, malunion and patient-reported outcomes in distal femur NPC fixation. Single-center retrospective study including all patients >18 years who sustained distal femur fractures treated with NPC. Primary outcomes were radiographic union, malunion and patient reported outcome measures at minimum 1-year follow-up. Secondary outcome measures included post-operative mobility, length of stay and complications. Relevant variables of normality are reported as mean with standard deviation. Subgroup analysis of patients aged <65 and ≥65 years are provided. Sixteen patients were included in the study. Rate of radiographic union was 100%. There was no case of malunion. All patients were allowed to bear full weight immediately post-operatively. Mean length of stay was 9.50 days, with 37.5% of patients discharged directly home. The majority (85.7%) of patients returned to pre-injury mobility. Early post-operative complications occurred in three patients. Three patients returned to theater. The mean EQ-5D-5L index value was 0.713, with 71.4% describing no problems with self-care and 85.7% reporting no or slight problems with usual daily activities. The NPC provided stable fixation permitting full weightbearing post-operatively with no cases of non or malunion. Return to pre-injury mobility and activity are encouraging. Based on these results we support the use of nail-plate construct fixation in the management of distal femur fractures.

Small-Fragment Plate Fixation of Humeral Shaft Fractures.

Fixation of humeral shaft fractures is frequently performed with large-fragment (4.5 mm) plates to accommodate immediate weight bearing. Use of small-fragment (3.5 mm) plates as an alternative carries theoretical benefits. We examined nonunion rates and postoperative radial nerve palsy (RNP) rates in a retrospective cohort of patients undergoing open reduction and internal fixation of humeral shaft fractures with 3.5-mm or 4.5-mm plates. Two hundred thirty-six patients with 241 humeral shaft fractures were included. Small 3.5-mm plates were used in 83% of the patients, and large 4.5-mm plates were used in 17% of the patients. Fifty-three percent were made weight bearing as tolerated following surgical fixation. There was a 7% incidence of nonunion and a 10% incidence of RNP in the 3.5-mm plate group. There was a 7% incidence of nonunion and a 15% incidence of RNP in the 4.5-mm plate group. No statistically significant relationship was shown between nonunion or RNP and plate size (P=.74 and P=.39). No relationship was shown between nonunion and postoperative weight-bearing status (P=.45). Subgroup analysis according to plate size additionally showed no association of nonunion with postoperative weight bearing in both the 4.5-mm (P=.55) and the 3.5-mm (P=.25) cohorts. Small-fragment and large-fragment plating of humeral shaft fractures resulted in comparable union and RNP rates, regardless of postoperative weight-bearing status. Our findings suggest that 3.5-mm plate fixation of humeral shaft fractures is a safe alternative to 4.5-mm plate fixation. [Orthopedics. 2023;46(4):198-204.].

Distal femur nonunion: Risk factors and validation of RUST scores

Abstract Objectives: (1) The purpose of this study was to investigate immediate postoperative weight-bearing status and other potential risk factors for nonunion after locked plating of distal femur fractures and (2) to compare clinical and radiographic union using the previously validated Radiographic Union Scale for Tibia (RUST) and modified RUST scores. Design: This is a retrospective cohort analysis. Setting: Academic Level-1 trauma center. Patients/Participants: Ninety patients with distal femur fractures (OTA/AO 33-A, including periprosthetic) treated with lateral locked plating over a 10-year period. Intervention: Distal femur fracture fixation with lateral locked plating; surgical intervention to facilitate bone healing in cases of nonunion. Main Outcome Measurements: Nonunion rate, construct rigidity scores, RUST, and modified RUST scores. Results: Seventy-eight of 90 patients (87%) achieved clinical union (13% nonunion rate). Rigidity score was significantly associated with risk of nonunion (P = 0.003). No significant association was detected between nonunion and postoperative weight-bearing status (P = 0.77) or other previously identified risk factors. Patients who achieved fracture union had significantly higher mean (SD) RUST (10.67 [1.37] vs. 6.53 [1.48], P &lt; 0.001) and modified RUST (13.47 [2.20] vs. 6.94 [1.79], P &lt; 0.001) scores than patients who developed nonunion. Sensitivity (Sn) analyses identified a RUST score threshold of 9 for diagnosing clinical union (Sn 93.6% and specificity [Sp] 91.7%) and a modified RUST score threshold of 8 (Sn 93.6%, Sp 91.7%). Conclusions: Immediate postoperative weight-bearing status does not seem to affect nonunion rates. We observed a statistically significant association between rigidity score and nonunion. This study supports the utility of the RUST and modified RUST scores in distal femur metaphyseal fractures. Level of Evidence: Therapeutic Level IV.

Treatment of Diaphyseal Tibial Fractures Distal to a Total Knee Arthroplasty by Intramedullary Nailing Is Safe and Effective.

To report the clinical result of a series of patients who underwent intramedullary nailing (IMN) of tibial shaft fractures distal to a total knee arthroplasty (TKA). Retrospective case series. Level-1 trauma center. Patients who sustained a tibial shaft fracture distal to a TKA treated with an IMN. IMN of tibial shaft fractures distal to a TKA. Postoperative weight-bearing status, readmissions, and complications or failure of treatment within 90 days; Knee Injury and Osteoarthritis Outcome Scores at the final follow-up; failure of treatment; and revision surgery. Nine patients were included. The average age was 71.4 years (range 55-87 years). All TKAs were cemented. The average distance between the tibial keel and the cortical density of the tibial tubercle was 24.1 mm (range 19.5-26.7 mm). Six nails were inserted using an infrapatellar portal, 2 were inserted using a suprapatellar portal, and 1 was inserted using a lateral parapatellar approach. The median nail diameter was 10 mm (range 9-12 mm). All fractures were healed at the final follow-up. There were no infections or arthroplasty-related complications. Knee Injury and Osteoarthritis Outcome Scores ranged from 100% to 74% (median 82%). Overall, we report on the largest cohort in the literature undergoing IMN of a tibial shaft fracture distal to a TKA. We demonstrate that IMN of diaphyseal tibial fractures distal to a TKA can be performed safely. We additionally demonstrate that this treatment is highly effective in achieving fracture union with no arthroplasty-related complications. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The effect of postoperative weight-bearing status on mortality rate following proximal femoral fractures surgery.

Proximal femur fractures are associated with an increased mortality rate in the elderly. Early weight-bearing presents as a modifiable factor that may reduce negative postoperative outcomes and complications. As such, we aimed to compare non-weight-bearing, partial-weight-bearing and full weight-bearing cohorts, in terms of risk factors and postoperative outcomes and complications. We retrospectively reviewed our database to identify the three cohorts based on the postoperative weight-bearing status the day of surgery from 2003 to 20014. We collected data on numerous risk factors, including age, cerebrovascular accident (CVA), pulmonary embolism (PE), surgical fixation method and diagnosis type. We also collected data on postoperative outcomes, including the number of days of hospitalization, pain levels, and mortality rate. We performed a univariate and multivariate analysis; P < 0.05 was the significant threshold. There were 186 patients in the non-weight-bearing group, 127 patients in the partial-weight-bearing group and 1791 patients in the full weight-bearing group. We found a significant difference in the type of diagnosis between cohorts (P < 0.001 in univariate, P < 0.001 in multivariate), but not in fixation type (P < 0.001 in univariate, but P = 0.76 in multivariate). The full weight-bearing group was diagnosed most with pertrochanteric fracture, 48.0%, and used Richard's nailing predominantly. Finally, we found that age was not a significant determinant of mortality rate but only weight-bearing cohort (P = 0.13 vs. P < 0.001, respectively). We recommend early weight-bearing, which may act to decrease the mortality rate compared to non-weight-bearing and partial weight-bearing. In addition, appropriate expectations and standardizations should be set since age and type of diagnosis act as significant predictors of weight-bearing status.

Do patients know their post-operative plan? A prospective cohort study of orthopaedic trauma patients at a level I trauma center

Patient compliance with weight bearing and physical therapy recommendations is critical following an orthopedic injury. Proper compliance requires knowledge of the postinjury plan, but there is little published data regarding comprehension of postinjury recommendations among orthopedic trauma patients. We hypothesized that patient knowledge of weight bearing and physical therapy instructions following an orthopaedic injury would be poor. Prospective Observational Cohort SETTING: Level I Trauma Center PATIENTS: 194 prospectively enrolled patients completed a questionnaire testing their knowledge of their weight bearing status and physical therapy plan at their first clinic visit following an inpatient admission with an orthopedic injury RESULTS: Despite the fact that 73% of patients were participating in physical therapy following hospital discharge, only 66% (95% CI 60-73%) of patients correctly identified their postinjury weight bearing status. A multivariate analysis found no significant correlation between chance of knowing postoperative weightbearing status or physical therapy plan and any of the socioeconomic patient factors we collected. Orthopedic trauma patients had a relatively poor understanding of even basic postinjury physical therapy instructions. This did not appear to be affected by age, gender, or socioeconomic factors. Orthopedic trauma surgeons should be aware of the significant potential for knowledge deficits among their patients and should make specific efforts to identify and correct those deficits.

51 A Prospective Study on Falls Efficacy and Functional Outcomes after HIP Fracture Surgery in a Singapore Orthogeriatric Programme

Abstract Introduction Fear of Falling (FoF) is common after hip fracture and associated with adverse outcomes including impaired functional recovery and recurrent falls. The objective of this study was to measure self-efficacy related to falls and its association with functional outcomes after hip fracture surgery. Methods A prospective cohort study was performed on 106 community-dwelling elderly aged ≥65 years without dementia, admitted to a community hospital for rehabilitation after surgery for fragility hip fracture in Singapore. They were managed in an integrated multidisciplinary orthogeriatric programme, transitioning from acute orthopaedic unit to the affiliated community hospital. Falls Efficacy Scale (FES; range 10-100) was assessed on discharge. Main outcomes measured included Parker Mobility Score (PMS) and Modified Barthel Index (MBI) at 3 months. Results Key characteristics of the cohort were: mean age 79.4(SD 6.38); female 74%, Chinese 83%, pre-fracture PMS 6.7(SD 2.7); pre-fracture MBI 81.1(SD 20.9); mean FES score 32.0(SD 23.7). At 3 months, mean PMS was 3.97(SD 2.51); mean MBI was 73(SD 20.1), demonstrating that the cohort overall did not regain their pre-morbid functional levels. FES was negatively correlated with both 3-month MBI and PMS with coefficients -0.592 and -0.523 respectively (p&amp;lt;0.001). FES was negatively associated with 3-month MBI and PMS in the multiple linear regression model, having adjusted for demographics, comorbidities, pre-fracture MBI and PMS, MMSE, geriatric depression scale, and post-operative weight-bearing status, with corresponding βs -0.26(95%CI -0.49 to -0.02;p=0.032) and -0.03(95%CI -0.06 to -0.00;p=0.044). Conclusion FoF is a potentially modifiable factor linked to adverse functional outcomes in hip fracture rehabilitation, indicating the necessity to address falls self-efficacy as a major component of assessment and intervention, whilst further exploring the local validity and applicability of various instruments measuring FoF. Further studies need to be conducted on the evolving patterns of FoF over time and its impact on longer-term functional and psychosocial outcomes.

Immediate weight bearing after plate fixation of fractures of the tibial plateau

Background There exists no consensus opinion as to the most suitable post-operative rehabilitation and weight bearing status for proximal tibia articular fractures treated with internal fixation using plates and screws. Objectives The aim of this study is to investigate whether the post-operative weight bearing status is associated with loss of reduction and articular collapse. Study Design and Methods Data was retrospectively analysed from our prospective database in a major trauma centre. Group I were non-weight bearing for the first six weeks post-operation and Group II were instructed to weight bear fully immediately post-operation. Radiographs were taken day one post-operation, at six weeks and at three months and analysed for fracture displacement and joint depression or loss of fixation. Results 90 patients were included in the study. The follow up radiographs demonstrated no failure of fixation in either study group. One patient from the weight bearing group had >1mm joint depression (4mm) identif...

Functional Outcomes Following Operative Treatment of Tibial Tubercle Fractures.

Quantitative evaluation of the functional results of surgically managed tibial tubercle fractures in adolescents is unreported in the orthopaedic literature. All patients treated surgically for unilateral tibial tubercle fractures at a single institution from 2007 to 2011 were invited to return for functional evaluation. Fractures were classified using the Ogden classification system. Clinical examination at follow-up included passive knee range of motion and thigh circumference. Side-to-side knee extension strength deficits were evaluated using a Biodex dynamometer. Patient-reported outcomes were assessed using the Pediatric-International Knee Documentation Committee Subjective Knee Form (Pedi-IKDC), Tegner-Lysholm Knee Scoring Scale, and Visual Analog Pain Scale. Chart review was performed to determine postoperative protocols including the use of physical therapy and protected weight bearing. Functional parameters were compared between the involved and uninvolved extremities using the Wilcoxon Signed Ranks Test and the Spearman correlations were performed to identify any relationships between perioperative factors, functional parameters, and subjective outcomes. In total, 19 of 42 patients completed clinical and functional testing and 18 of 19 completed all outcome surveys. Average age at injury was 13.9 years and average follow-up was 3.0 years. There was no statistical difference in knee range of motion between sides, however, thigh circumference was slightly smaller in the injured extremity (median difference, 1.7 cm at 15 cm above the patella and 4.0 cm at 50% of the length of the thigh). In total 5/19 subjects (26%) had a significant quadriceps extension strength deficit on the involved leg compared with the contralateral side. The median Visual Analog Pain Scale for affected limbs was 8/100 and for unaffected limbs was 6/100 (P=0.017). The Tegner-Lysholm Scale revealed 9 excellent results, 5 good, 4 fair, and 1 poor (median, 90/100). Results of the Pedi-IKDC were 11 excellent, 3 good, 2 fair, and 3 poor results (median, 91/100). Outcome scores did not correlate to diminished strength or thigh circumference. No difference in outcome based upon body mass index, postoperative weight-bearing status, Ogden classification, or postoperative physical therapy was noted using regression analysis. Despite promising objective results, clinical outcomes measured by subjective validated surveys are not all excellent. Level III.

Outcome of femoral fractures in poliomyelitis patients.

As patients who were afflicted with poliomyelitis during the outbreaks in the past are aging, lower extremity osteoporotic fractures are becoming more frequent. Fixation in deformed, porotic bone, coupled with muscle weakness and imbalance creates a unique challenge when treating these fractures as does their reduced rehabilitation potential. The aim of this study was to investigate the outcome of femoral fractures in surviving poliomyelitis patients. Sixty-five patients with 74 femoral fractures were treated between 1990 and 2014. Clinical outcome was assessed using the Parkland and Palmer mobility score, and quality-of-life was assessed using the SF-12® score. Some 84% of the fractures were a result of low-energy mechanisms and occurred in the polio-affected limbs, but nonaffected limbs were also injured owing to low-energy mechanisms in all cases. Fifty-seven fractures were treated operatively. There were nine re-operations (16%), including implant removals, nonunion, peri-implant fractures, and malunion. Some 60% of the patients did not regain their previous ambulatory capacity. Post-operative weight-bearing status did not correlate with the final functional outcome. Polio patients with femoral fractures have a guarded prognosis for regaining their pre-injury ambulatory capacity. A higher re-operation rate than that with "normal" osteoporotic fractures is expected.

Variability and Comprehensiveness of North American Online Available Physical Therapy Protocols Following Hip Arthroscopy for Femoroacetabular Impingement and Labral Repair

To assess comprehensiveness and variability of postoperative physical therapy protocols published online following hip arthroscopy for femoroacetabular impingement (FAI) and/or labral repair. Surgeons were identified by the International Society for Hip Arthroscopy "Find a Surgeon" feature in North America (http://www.isha.net/members/, search August 10, 2016). Exclusion criteria included nonsurgeons and protocols for conditions other than hip arthroscopy for FAI and/or labral tear. Protocols were identified by review of surgeons' personal and departmental websites and evaluated for postoperative restrictions, rehabilitation components, and the time points for ending restrictions and initiating activities. Of 111 surgeons available online, 31 (27.9%) had postoperative hip arthroscopy physical therapy protocols available online. Bracing was used in 54.8% (17/31) of protocols for median 2-week duration (range, 1-6weeks). Most protocols specified the initial postoperative weight-bearing status (29/31, 93.5%), most frequently partial weight-bearing with 20 pounds foot flat (20/29, 69.0%). The duration of weight-bearing restriction was median 3weeks (range, 2-6) for FAI and median 6weeks (range, 3-8) for microfracture. The majority of protocols specified initial range of motion limitations (26/31, 83.9%) for median 3weeks (range, 1.5-12). There was substantial variation in the rehabilitation activities and time points for initiating activities. Time to return to running was specified by 20/31 (64.5%) protocols at median 12weeks (range, 6-19), and return to sport timing was specified by 13/31 (41.9%) protocols at median 15.5weeks (range, 9-23). There is considerable variability in postoperative physical therapy protocols available online following hip arthroscopy for FAI, including postoperative restrictions, rehabilitation activities, and time points for activities. This information offers residents, fellows, and established hip arthroscopists a centralized comparison of publicly available physical therapy protocols following hip arthroscopy. Practicing arthroscopists might find this analysis useful to compare various therapy strategies to their own recommendations. The variability we report can also provide inspiration for future efficacy research toward a more standard rehabilitation.

Acetabular fracture associated with cementless acetabular component insertion: A report of 13 cases

Acetabular fracture during insertion of a cementless acetabular component occurred in 13 patients. The preoperative diagnosis was osteoarthritis in 6 patients, rheumatoid arthritis in 2 patients, avascular necrosis in 3 patients, hip fracture nonunion in 1 patient, and developmental dysplasia of the hip in 1 patient. Several different components were used; however, the acetabulum was underreamed by 1 to 3 mm in all cases. The acetabular fracture was identified in 9 of 13 cases intraoperatively. The fracture was identified on postoperative radiographs for the other 4 cases. Fractures were treated by a variety of means, including the addition of augmentation screws in or around the cup, use of autograft bone at the fracture site, modified postoperative weight-bearing status, and immobilization. In 2 cases, the socket needed to be revised after it progressively migrated and failed. One patient had cup migration, and another had a radiolucent line about the cup but was not symptomatic enough to require revision. In 3 of these 4 cases, the fracture was not identified intraoperatively. Underreaming of the acetabulum and use of an oversized acetabular component has been recommended to improve the initial stability of the acetabular component during total hip arthroplasty. Impaction of an oversized component requires bone to undergo plastic deformation if the cup is to be fully seated. Theoretically, this technique provides improved component stability with enhanced osseous ingrowth into the cup. The 13 cases reported in this study demonstrate that acetabular fracture is a complication that may occur in association with uncemented hip arthroplasty, particularly if oversized components are used. The importance of recognizing acetabular fractures intraoperatively and the need to institute appropriate treatment to ensure a stable acetabular component is emphasized. In patients with osteoporotic bone, line-to-line reaming with use of a cementless acetabular component or insertion of a cemented socket may be considered to avoid this significant complication.