Weight-bearing Protocol Research Articles

Early Weightbearing After Operatively Treated Trimalleolar Ankle Fractures with Large Posterior Malleolar Fragments

Category: Trauma Introduction/Purpose: No consensus exists regarding postoperative rehabilitation protocols after surgical fixation of unstable trimalleolar ankle fractures with large posterior malleolar fragments. Additionally, no consensus exists regarding type of fixation of large posterior malleolar fragments in these fractures. It is unclear whether clinical results with early weightbearing differ between large posterior malleolar fragments fixed with either screws alone or a plate and screws construct. We evaluated fracture displacement with simulated early weightbearing in a cadaveric model. Methods: Sixteen fresh-frozen lower extremities were assigned to Group 1, trimalleolar ankle fracture with a large posterior malleolar fragment fixed with screws (n=8) or Group 2, trimalleolar ankle fracture with a large posterior malleolar fragment fixed with a plate and screws construct (n=8). Both Groups were tested with an axial compressive load at 3.2 Hz from 100 to 1,000 N and internal/external torque at 1.6 Hz at 0.5 Nm for 250,000 cycles to simulate 5 weeks of full weightbearing. Displacement was measured by differential variable reluctance transducer. Results: The average motion at all fracture sites in both groups was less than 1 mm. Group 1 displacement of the medial, lateral, and posterior malleolar fracture was 0.30 ± 0.27 mm, 0.12 ± 0.11 mm, and 0.87 ± 0.68 mm respectively. Group 2 displacement of the medial, lateral, and posterior malleolar fracture was 0.78 ± 1.52 mm, 0.12 ± 0.16 mm, and 0.87 ± 1.20 mm respectively. There was no significant difference between the average motion at all fractures sites between Group 1 and Group 2 (P > 0.05). There was no statistical correlation between fracture displacement and bone mineral density. Conclusion: This study supports early weightbearing after surgical fixation of unstable trimalleolar ankle fractures regardless of type of fixation of the posterior malleolus. Further investigation of early weightbearing protocols after surgical fixation of unstable trimalleolar ankle fractures are needed to help guide future treatment.

Rehabilitation after plate fixation of upper and lower extremity fractures

Post-operative rehabilitation and weight-bearing protocols are important to fracture fixation outcomes, yet there is a dearth in the literature concerning universal treatment guidelines following plate fixation of extremity fractures. There are controversies regarding time to allow weight-bearing and range of motion for most fractures of the upper and lower extremity. This lack of a consensus has led to varying practice guidelines and differing anecdotal protocols between treating surgeons. This review attempts to establish consensus guidelines for the post-operative rehabilitation required for patients following plate fixation of common upper and lower extremity fractures.

Early Weightbearing Protocol in Operative Fixation of Acute Jones Fractures

The treatment of Jones fractures has been controversial in terms of nonoperative versus operative management, given the high incidence of nonunion secondary to the delicate blood supply to the proximal fifth metatarsal. We report a retrospective review of a patient cohort treated with an early weightbearing protocol after operative intramedullary fixation in acute Jones fractures. Thirty-one consecutive patients with an acute Jones fracture underwent operative fixation with a single intramedullary solid screw. The postoperative protocol consisted of immediate weightbearing in a controlled ankle motion boot for 2 weeks with a gradual transition to regular shoes at 2 weeks postoperative. At 2 weeks, the patients were allowed to perform low-impact activities such as walking, swimming, biking, or elliptical training. Patients were allowed to return to all activities, as tolerated, regardless of radiographic healing, at 6 weeks postoperatively. Serial postoperative radiographs were taken at 2-week intervals to determine radiographic union. Our patient population consisted of 24 males (77.42%) and 7 females (22.58%), with a mean average age of 37.5 ± 12.59 years and mean average body mass index of 25.7 ± 2.32 kg/m2. Fracture union was observed in all 31 patients (100%) at a mean average of 5.7 ± 1.47 (range 4 to 10) weeks. Two (6.5%) patients required hardware removal, with one (3.2%) experiencing sural neuritis. This review of patients undergoing early weightbearing after operative fixation of an acute Jones fracture demonstrated a satisfactory incidence of union compared with traditional postoperative protocols at a mean follow-up duration of 18.58 ± 5.66 months.

Intramedullary nailing in opening wedge high tibial osteotomy-in vitro test for validation of a method of fixation.

Opening wedge high tibial osteotomy (HTO) as a treatment in unicompartimental osteoarthritis of the knee can significantly relieve pain and prevent or at least delay an early joint replacement. The fixation of the osteotomy has undergone development and refinements during the last years. The angle-stable plate fixator is currently one of the most commonly used plates in HTOs. The angular stable fixation between screws and the plate offers a high primary stability to retain the correction with early weight-bearing protocols. This surgical technique is performed as a standard of care and generally well tolerated by the patients. Nevertheless, some studies observed that many patients complained about discomfort related to the implant. Therefore, the stability of two different intramedullary nails, a short implant used in humeral fractures and a long device used in tibial fractures for stabilization in valgus HTOs, was investigated as an alternative fixation technique. The plate fixator was defined as reference standard. Nine synthetic tibia models were standardly osteotomized and stabilized by one of the fixation devices. Axial compression was realized using a special testing machine and two protocols were performed: a multi-step fatigue test and a load-to-failure test. Overall motion, medial, and lateral displacements were documented. Fractures always occurred at the lateral cortex. Axial cyclic loading up to 800N was tolerated by all implants without failure. The tibia nail provided highest fatigue strength under the load-to-failure conditions. The results suggest that intramedullary nailing might be used as an alternative concept in HTO.

Immediate Weight Bearing After Hallux Valgus Correction Using Locking Plate Fixation of the Ludloff Osteotomy: A Retrospective Review.

A Ludloff osteotomy is a common procedure used to correct hallux valgus deformities. Traditionally, the osteotomy is stabilized with screws only, thus requiring the patient to be non-weight bearing until healed. There have been no outcome studies analyzing immediate weight bearing after Ludloff osteotomy for hallux valgus. Of the 350 patients (390 feet) who underwent a Ludloff osteotomy fixed with a locking plate and prescribed an immediate weight-bearing postoperative protocol, 288 patients (326 feet) were included in the analysis. Average radiographic follow-up was 8 months, and hallux-valgus angle (HVA), intermetatarsal angle (IMA), and any hardware failures or hypertrophic callus formation were recorded. The Foot Function Index (FFI) was assessed in 103 patients at an average of 44 months postoperatively. Average IMA and HVA correction were 7.6° and 21.6°, respectively (P < .0001). Loss of HVA and IMA correction of 4.6° and 2.3°, respectively, were noted between the initial postoperative films and final weight-bearing films. The average FFI score calculated for the 103 respondents was 10.4 out of a possible 100, indicating relatively low pain and disability. Complication rates were consistent with most other published postoperative protocols, with the most commonly seen being superficial infection (4.9%) and symptomatic hardware (4.6%). An immediate weight-bearing protocol for Ludloff osteotomies fixed with locking plates results in recurrence rates that are similar to those found with other protocols. Patient function is quite high and pain low following this protocol. The most commonly observed complications were superficial infection and symptomatic hardware requiring removal. Level IV.

Immediate weight-bearing after locking plate fixation of the Ludloff osteotomy

Category: Bunion Introduction/Purpose: One of the more common and versatile osteotomies to correct moderate hallux valgus deformities is the Ludloff osteotomy. This oblique osteotomy is typically stabilized with screws and patients kept non-weight bearing until healed. Complications include malunion, nonunion and loss of correction, which can occur due to poor compliance with non- weight bearing protocols. Elderly, obese and physically weak patients can have difficulty remaining non-weight bearing. A novel anatomic-locking plate and fixation method was developed that allows immediate weight bearing after a Ludloff osteotomy. We analyzed the results of a consecutive cohort of patients who underwent a Ludloff osteotomy stabilized with this method. The cohort included all patients presenting with a moderate to severe hallux valgus deformities. Complications, radiographic &amp; clinical outcomes were studied. Methods: In this IRB approved retrospective cohort study, we analyzed clinical &amp; radiographic data of all Ludloff osteotomies performed between 2010 and 2015. Preoperative and postoperative data included Foot Function Index, intermetatarsal &amp; hallux valgus angles, complications, callus formation &amp; clinical outcomes. 395 feet in 350 patients were examined. 6 patients (2.1%) were male. 43 feet were excluded due to incomplete films and 21 were excluded due to screw fixation only; requiring restricted post- operative weightbearing protocols. Three surgeons performed the surgeries and review/analyses conducted by a senior orthopedic resident, uninvolved with the care of any of the patients. Indications included symptomatic hallux valgus deformities (intramedullary angle greater than 10°), failure of conservative treatment and normal preoperative range of motion. Exclusion criteria included 1st tarsometatarsal joint arthritis/instability, peripheral neuropathy, vascular disease and 1st metatarsophalangeal joint arthritis. Preoperative and postoperative radiographs were weightbearing. Patients discharged when comfortable in normal shoes. Results: At an average of 8 months postop (2 - 43 months), there was an average hallux valgus (HVA) correction angle correction of 7.6° (p&lt;.0001) and intermetatarsal angle (IMA) correction of 21° from initial to final radiographs. Patients were discharged when comfortable in normal shoes. In the 15 feet (4.6%) who formed hypertrophic callus, there was loss of IMA of 2.3° (p&lt;.0001) and HVA of 4.6° (p&lt;.0001). Superficial wound infection or mild cellulitis was noted in 16 feet (4.9°); no deep infections. 15 (4.6%) feet had hardware removal due to prominent and/or broken screws. These were in older women with thin feet. There was only 1 nonunion &amp; 8 mal-unions. An average foot function index (in 70 patients) of 9.5/100 indicated low pain and disability. Conclusion: The data from this large series of patients (395 osteotomies) supports the use of an immediate weight-bearing protocol for Ludloff osteotomies fixed with anatomic locking plates, including patients with osteopenic bone. All patients were allowed activities and weight bearing as tolerated during the post-operative period. There were relatively few complications including loss of correction or nonunion. Patients and surgeons can expect healing and complication rates similar to osteotomies fixed with screws and a non-weight-bearing post-operative protocol. Furthermore, because of the increased stability imparted by the anatomic locking plate, it would be a good option for revision bunion surgery.

Can antibiotic impregnated cement nail achieve both infection control and bony union in infected diaphyseal femoral non-unions?

BackgroundInfected non-union is complex and debilitating disorder affecting orthopaedic surgeon and patient in terms of cost and time. Many methods are described in the literature for treatment of infected non-union. Local high concentration of antibiotic and mechanical stability of antibiotic cement impregnated intramedullary nail (ACIIN) proves cost and time effective. Recently it was suggested that ACIIN can achieve both union and infection control in infected non-unions with bone gap less than 4cm. The aim of our study was to investigate this hypothesis and study the outcome of antibiotic cement impregnated intramedullary nail in term of both infection control and osseous union. Materials and methodsWe retrospectively studied 21 patients with infected diaphyseal femoral non-union. Inclusion criteria were bone gap less than 4cm after debridement and more than 1 year follow-up of the case. ACIIN prepared using K nail was used as primary procedure after adequate debridement. Infection control and osseous union was judged on the basis of clinical, radiological and haematological parameters. All patients were followed up with an average follow-up of 20.23±3.65 months (range 14–28 months). ResultsInfection control was achieved in all 21 patients at end of 12 months follow-up, out of which 16 patients had osseous union and infection control without any secondary procedure. Of the remaining 5 patients: two patients had good infection control but had broken ACCIN due to non-compliance to weight bearing protocol. One patient underwent exchange nailing and plate augmentation whilst the other underwent simple exchange nailing, One more patient who had infection control but had persistent non-union had to undergo exchange nailing and augmented plating to achieve union. One other patient required debridement and implant removal and attained union and fifth patient required two additional debridements to control infection after which the fracture united. Apart from above 5 cases there were two further complications of knee stiffness. ConclusionIn infected non-union with bone gap less than 4cm, ACIIN can achieve both infection control and osseous union in significant number of cases. All such cases should be primarily operated with aim to achieve this outcome and use of thicker nail and ensuring proper compliance from patients regarding weight bearing will improve the outcomes.

Effect of 8-Week Lower Extremity Weight-Bearing Exercise Protocol and Acute Caffeine Consumption on Reaction Time in Postmenopausal Women

Effect of 8-Week Lower Extremity Weight-Bearing Exercise Protocol and Acute Caffeine Consumption on Reaction Time in Postmenopausal Women

Early Versus Late Weight-Bearing Protocols for Surgically Managed Posterior Wall Acetabular Fractures.

Despite overall improved outcomes with open reduction and internal fixation of acetabular fractures, posterior wall fractures show disproportionately poor results. The effect of weight bearing on outcomes of fracture management has been investigated in many lower extremity fractures, but evidence-based recommendations in posterior wall acetabular fractures are lacking. The authors systematically reviewed the current literature to determine if a difference in outcome exists between early and late postoperative weight-bearing protocols for surgically managed posterior wall acetabular fractures. PubMed and MEDLINE were searched for posterior wall acetabular fracture studies that included weight-bearing protocols and Merle d'Aubigné functional scores. Twelve studies were identified. Each study was classified as either early or late weight bearing. Early weight bearing was defined as full, unrestricted weight bearing at or before 12 weeks postoperatively. Late weight bearing was defined as restricted weight bearing for greater than 12 weeks postoperatively. The 2 categories were then compared by functional score using a 2-tailed t test and by complication rate using chi-square analysis. Six studies (152 fractures) were placed in the early weight-bearing category. Six studies (302 fractures) were placed in the late weight-bearing category. No significant difference in Merle d'Aubigné functional scores was found between the 2 groups. No difference was found regarding heterotopic ossification, avascular necrosis, superficial infections, total infections, or osteoarthritis. This systematic review found no difference in functional outcome scores or complication rates between early and late weight-bearing protocols for surgically treated posterior wall fractures. [Orthopedics. 2017: 40(4):e652-e657.].

Functional outcome after early mobilization in isolated subtalar dislocation: Case report and review of current evidence

Isolated subtalar dislocation (SD) is an exceptionally rare foot injury. Prompt gentle reduction, injury severity, and duration of postreduction immobilization are prognostic determinants of functional outcome. Consensus has eluded the orthopedic community regarding optimal duration of immobilization and weight-bearing protocol, following successful reduction of SDs. This case report highlights the functional outcome following early postreduction immobilization and weight-bearing in isolated SD and reviews the current evidence.

Hip arthroscopy protocol: expert opinions on post-operative weight bearing and return to sports guidelines.

The objectives of this study are to survey the weight-bearing limitation practices and delay for returning to running and impact sports of high volume hip arthroscopy orthopedic surgeons. The study was designed in the form of expert survey questionnaire. Evidence-based data are scares regarding hip arthroscopy post-operative weight-bearing protocols. An international cross-sectional anonymous Internet survey of 26 high-volume hip arthroscopy specialized surgeons was conducted to report their weight-bearing limitations and rehabilitation protocols after various arthroscopic hip procedures. The International Society of Hip Arthroscopy invited this study. The results were examined in the context of supporting literature to inform the studies suggestions. Four surgeons always allow immediate weight bearing and five never offer immediate weight bearing. Seventeen surgeons provide weight bearing depending on the procedures performed: 17 surgeons allowed immediate weight bearing after labral resection, 10 after labral repair and 8 after labral reconstruction. Sixteen surgeons allow immediate weight bearing after psoas tenotomy. Twenty-one respondents restrict weight bearing after microfracture procedures for 3–8 weeks post-operatively. Return to running and impact sports were shorter for labral procedures and bony procedures and longer for cartilaginous and capsular procedures. Marked variability exists in the post-operative weight-bearing practices of hip arthroscopy surgeons. This study suggests that most surgeons allow immediate weight bearing as tolerated after labral resection, acetabular osteoplasty, chondroplasty and psoas tenotomy. For cartilage defect procedures, 6 weeks or more non-weight bearing is suggested depending on the area of the defect and lateral central edge angle. Delayed return to sports activities is suggested after microfracture procedures. The level of evidence was Level V expert opinions.

Biomechanical Comparison of 3 Current Ankle Syndesmosis Repair Techniques

Significant debate exists regarding optimal repair for unstable syndesmosis injuries. Techniques range from screw fixation, suture-button fixation, or a combination of the two. In this study, 3 common repairs were compared using a simulated weightbearing protocol with internal and external rotation of the foot. Twenty-four lower leg specimens with mean age 54 years (range, 38-68 years) were used for testing. Following creation of a complete syndesmotic injury (AITFL, ITFL, PITFL, interosseous membrane), specimens were repaired using 1 of 3 randomly assigned techniques: (1) one 3.5-mm syndesmotic screw, (2) 1 suture-button construct, and (3) 2 divergent suture-button constructs. Repairs were cycled for 500 cycles between 7.5 Nm of internal/external rotation torque under a constant 750 N axial compressive load in a neutral dorsiflexion position. At 0, 10, 100, and 500 cycles, torsional cyclic loading was interrupted to assess torsional resistance to rotation within a physiologic range of motion (15 degrees external rotation to 10 degrees internal rotation). Torque (Nm), rotational position (degrees), and 3-dimensional data were collected throughout the testing to characterize relative spatial relationships of the tibiofibular articulation. There were no significant differences between repair techniques in resistance to internal and external rotation with respect to the intact syndesmosis. Three-dimensional analysis revealed significant differences between repair techniques for sagittal fibular translation with external rotation of the foot. Screw fixation had the smallest magnitude of posterior sagittal translation (2.5 mm), and a single suture-button construct demonstrated the largest magnitude of posterior sagittal translation (4.6 mm). Screw fixation also allowed for significantly less anterior sagittal translation with internal rotation of the foot (0.1 mm) when compared to both 1 (2.7 mm) and 2 (2.9 mm) suture-button constructs. All repairs provided comparable rotational stability to the syndesmosis; however, no repair technique completely restored rotational stability and tibiofibular anatomic relationships of the preinjury state. Constructs were comparable across most conditions; however, when repairing injuries with a suture-button construct, a single suture-button construct may not provide sufficient resistance to sagittal translation of the fibula.

Repair of the Ankle Syndesmosis

Objectives:Significant debate exists regarding the optimal repair techniques for unstable syndesmosis injuries. Techniques range from one to multiple screw fixation, suture-button fixation devices, or a combination of the two. The purpose of the current investigation was to biomechanically compare three common syndesmotic repair techniques using a simulated weight-bearing protocol with internal and external rotation of the foot.Methods:Twenty-four, lower leg specimens with mean age 54.25 years (range, 38 to 68 years) were utilized for testing. Following the creation of a complete syndesmotic injury (AITFL, ITFL, PITFL, interosseous membrane) specimens were repaired using one of three randomly assigned repair techniques: (1) one 3.5 mm syndesmotic screw, (2) one suture-button construct, and (3) two divergent suture-button constructs. For testing, specimens were oriented in neutral plantar/dorsiflexion and neutral internal/external rotation with the respect to the vertical tibia. Repairs were then cycled for 500 cycles between 7.5 Nm of internal/external rotation torque under a constant 750 N axial compressive load. At 0, 10, 100, and 500 cycles, torsional cyclic loading was interrupted to assess torsional stiffness and resistance to rotation within a physiologic range of motion. While axially loaded to 750 N, the foot was externally rotated to 15° and then rotated to 10° of internal rotation. Torsional cyclic loading was then resumed. Torque (Nm) and rotational position (degrees) were recorded continuously throughout testing. Three-dimensional data was also collected throughout testing to characterize the relative spatial relationships of the tibiofibular articulation.Results:Biomechanically, there were no significant differences between techniques when repairs were compared to the intact syndesmosis. Three-dimensional analysis revealed significant differences between all repair techniques for sagittal fibular translation with external rotation of the foot. Screw fixation had the smallest magnitude in sagittal translation (-2.5 mm), and a single suture-button construct demonstrated the largest magnitude of sagittal translation (-4.6 mm). Screw fixation also allowed for significantly lower sagittal translation with internal rotation of the foot (0.1 mm) when compared to both one (2.7 mm) and two (2.9 mm) suture-button repair constructs.Conclusion:All repairs provided a significant resistance to internal and external rotation, and only demonstrated mild reductions in strength and torsional stiffness throughout torsional cyclic testing.

Are current methods of partial weight-bearing instruction accurately translating to crutch-assisted gait?

Background/Aims: Partial weight-bearing protocols are commonly incorporated into hospital, clinical and field-based rehabilitation to enhance recovery, particularly in patients following cartilage surgeries. Overloading can affect healing time and the stability or integrity of the healing structure, however underloading can also be detrimental, as adequate weight bearing encourages the healing process—for example, osteoblastic stimulation. Therefore, accurate reproducibility of these protocols could be considered essential to the rehabilitation process. The aim of this study was to determine the accuracy with which weight-bearing protocols (20%, 50% or 80% of body weight) could be reproduced shortly after being taught. Methods: Thirty participants were taught three partial weight-bearing protocols (20%, 50% and 80% of body weight), using bathroom scales. Participants ability to reproduce their target load for each protocol was assessed statically using bathroom scales and dynamically with a force plate using a three-point elbow crutch-assisted gait. Participants were assessed 10 minutes after being taught. Errors between actual and target load during these trials was calculated. Findings: Accuracy assessed with scales was comparatively good for all target loads, however dynamic trials using the force plate showed an inverse relationship between all error measures and target loads (i.e. 20% &gt; 50% &gt; 80% body weight; all P&lt;0.01). The peak error was double the intended load at 20% of body weight (95% CI: 11.9% body weight, 24.1% body weight). At 80% of body weight, the peak error was not significantly different from zero. Conclusions: The static method of instruction of partial weight-bearing protocols, using bathroom scales, does not seem to translate accurately to dynamic motion, and therefore affects adherence to medical instruction. Practitioners should be aware of the potential errors in reproducing these loads and the potential effect on rehabilitation. These results would suggest that practitioners should be cautious when using bathroom scales to teach partial weight-bearing protocols and not to rely on them to assess reproduction accuracy during gait.

Management of Posterior Cruciate Ligament Injuries

Isolated injuries of the posterior cruciate ligament are uncommon, are often caused by a posteriorly directed force to the proximal tibia, and result in abnormal knee kinematics and function. A thorough clinical evaluation, including history, physical examination, and imaging, is required to rule out a concomitant structural knee injury. No clear prognostic factors predict outcomes, and ideal management remains uncertain. Nonsurgical management is advocated for isolated grade I or II posterior cruciate ligament injuries or for grade III injuries in patients with mild symptoms or low activity demands. Surgical management is reserved for high-demand athletes or patients in whom nonsurgical management has been unsuccessful. Although biomechanical studies have identified differences between single-bundle, double-bundle, transtibial, and tibial inlay reconstruction techniques, the optimal surgical technique has not been established. No high-quality evidence is available regarding immobilization, weight-bearing, bracing, or rehabilitation protocols for patients treated either nonsurgically or surgically. Additional long-term clinical studies with homogeneous patient populations are needed to identify the ideal management of these injuries.

Prospective Use of a Standardized Nonoperative Early Weightbearing Protocol for Achilles Tendon Rupture

Background: Acute traumatic rupture of the Achilles tendon can be treated operatively or nonoperatively. Throughout the literature, there is no consensus regarding the optimal treatment protocol. Purpose: To report on 17 years of experience with treating this injury with a standardized nonoperative treatment protocol. Study Design: Case Series; Level of evidence, 4. Methods: The treatment protocol was based on a combination of an equinus cast and rehabilitation boot, which promoted immediate full weightbearing and early functional rehabilitation. A total of 171 patients were consecutively treated and prospectively followed from 1996 to 2013. Assessed were subjective parameters such as pain, loss of strength, return to previous activity level, meteosensitivity, and general satisfaction with the treatment outcome. Clinical assessment included testing of plantar flexion strength and endurance, calf circumference, and tendon length. Subjective and clinical parameters were then used to calculate a modified Thermann score. The correlation between tendon lengthening and function was calculated using the Pearson correlation coefficient. Results: A total of 114 patients were followed for a minimum of 12 months (mean, 27 ± 20 months; range, 12-88 months). The mean Thermann score was 82 ± 13 (range, 41-100), and subjective satisfaction was rated “very good” and “good” in 90%. An inverse correlation was found between tendon length and muscle strength (R = −0.3). There were 11 reruptures (8 with and 3 without an adequate trauma). General complications were 5 deep venous thromboses, 1 complex regional pain syndrome, and minor problems such as transient heel pain (n = 3), heel numbness (n = 1), and cast-associated skin abrasions (n = 4). Conclusion: Seventeen years of experience with a nonoperative treatment protocol for acute rupture of the Achilles tendon confirmed good functional outcome and patient satisfaction. Reruptures mostly occurred with new traumatic events in the vulnerable phase from 6 to 12 weeks after the initial injury. Muscle strength correlated to tendon length, making its assessment a crucial follow-up parameter. The protective equinus cast and boot can protect against excessive tendon lengthening during the healing process.

Lengthening of the Femur with a Remote-Controlled Magnetic Intramedullary Nail: Retrograde Technique.

Femoral lengthening with an intramedullary nail inserted through a retrograde approach offers the unique benefit of accurate deformity correction and distraction osteogenesis without the need for external fixation with its inherent challenges. The key to a successful deformity correction and proper nail placement is preoperative planning. Insert 2 Steinmann pins or half-pins into the proximal and distal aspects of the femur to mark any rotational deformity that is being corrected or to ensure that no rotational deformity is created. The Steinmann pins need to be ≥3 mm in diameter to prevent bending with loss of rotational reference. We prefer 5-mm or 6-mm Schanz pins for this role. These sturdy pins may be used as a "joystick" for manipulating the distal fragment to achieve a correction. This step includes the approach to and reaming of the distal fragment, which is critical to the limb alignment. Perform the percutaneous osteotomy, which allows for correction of the deformity, prior to reaming the proximal segment. While holding the distal fragment in the reduced position, prepare the proximal fragment for nail insertion. Insert the nail in a standard fashion, avoiding excessive force that could damage it or jam it into the proximal fragment. Lock the nail from the distal or proximal end first. The femoral distractor helps to keep the rotation accurate during locking and helps to serve as a handle to obtain perfect overlapping circles of the locking screw site on fluoroscopy. However, the external fixator may be obstructive for distal locking in particular. The fixator can be removed for distal locking and reattached for proximal locking. Check the anteroposterior and lateral fluoroscopic images and decide how stable the nail is in the bone. Will the fragment shift into varus, valgus, or flexion? Mark the position and orientation of the magnet in the nail on the patient's skin to indicate where to place the external magnet for lengthening. Postoperative management involves nail distraction, venous thromboembolic (VTE) prophylaxis, and adherence to a specific weight-bearing protocol. Femoral lengthening with the remote-controlled magnetic intramedullary nail has had excellent clinical efficacy3.

Failed Surgical Management of Acute Proximal Fifth Metatarsal (Jones) Fractures: A Retrospective Case Series and Literature Review.

Nonunion, delayed union, and refracture after operative treatment of acute proximal fifth metatarsal fractures in athletes is uncommon. This study was a failure analysis of operatively managed acute proximal fifth metatarsal fractures in healthy athletes. We identified 149 patients who underwent operative treatment for fifth metatarsal fractures. Inclusion criteria isolated skeletally mature, athletic patients under the age of 40 with a minimum of 1-year follow-up. Patients were excluded with tuberosity fractures, fractures distal to the proximal metaphyseal-diaphyseal region of the fifth metatarsal, multiple fractures or operative procedures, fractures initially treated conservatively, and medical comorbidities/risk factors for nonunion. Fifty-five patients met the inclusion/exclusion criteria. Four (7.3%) patients required a secondary operative procedure due to refracture. The average time to refracture was 8 months. All refractures were associated with bent screws and occurred in male patients who participated in professional basketball, professional volleyball, and college football. The average time for release to progressive weight-bearing was 6 weeks. Three patients were revised to a bigger size screw and went on to union. One patient was revised to the same-sized screw and required a second revision surgery for nonunion. All failures were refractures in competitive athletes who were initially treated with small diameter solid or cannulated stainless steel screws. The failures were not associated with early postoperative weight-bearing protocol. Maximizing initial fixation stiffness may decrease the late failure rate in competitive athletes. More clinical studies are needed to better understand risk factors for failure after screw fixation in the competitive, athletic population. Prognostic, Level IV: Case series.

Weightbearing Versus Nonweightbearing After Meniscus Repair.

Context:Optimal rehabilitation after meniscal repair remains controversial.Objective:To review the current literature on weightbearing status after meniscal repairs and to provide evidence-based recommendations for postoperative rehabilitation.Data Sources:MEDLINE (January 1, 1993 to July 1, 2014) and Embase (January 1, 1993 to July 1, 2014) were queried with use of the terms meniscus OR/AND repair AND rehabilitation.Study Selection:Included studies were those with levels of evidence 1 through 4, with minimum 2 years follow-up and in an English publication.Study Design:Systematic review.Level of Evidence:Level 4.Data Extraction:Demographics and clinical and radiographic outcomes of meniscus repair at a minimum of 2 years follow-up were extracted.Results:Successful clinical outcomes ranged from 70% to 94% with conservative rehabilitation. More recent studies using an accelerated rehabilitation protocol with full weightbearing and early range of motion reported 64% to 96% good results.Conclusion:Outcomes after both conservative (restricted weightbearing) protocols and accelerated rehabilitation (immediate weightbearing) yielded similar good to excellent results; however, lack of similar objective criteria and consistency among surgical techniques and existing studies makes direct comparison difficult.

Periprosthetic femur fractures.

Successful treatment of periprosthetic femur fractures, like all fractures, requires careful attention to understand the fracture pattern nuances, identifying and executing a rational treatment approach, and providing an appropriate postoperative recovery protocol. Unlike most other fractures, modification of standard techniques is often required to obtain a stable fixation construct, and there is a greater role for revision arthroplasty in the treatment of periprosthetic fractures. Optimal indications for surgical repair versus revision arthroplasty and optimal postoperative weight-bearing protocols remain uncertain. Reported outcomes for patients with periprosthetic femoral shaft fractures are generally good and are relatively consistent. Results for periprosthetic distal femur fractures, however, are less good and more inconsistent. Both periprosthetic femoral shaft and distal femur fractures are associated with relatively high mortality rates, approaching that of patients with hip fractures. This review should provide insight into the current solutions and challenges for the treatment of patients with periprosthetic femur fractures.