Weight-bearing As Tolerated Research Articles

Racial and Ethnic Disparities in Providing Guideline-Concordant Care After Hip Fracture Surgery

Institutions have adopted protocol-driven standardized hip fracture programs (SHFPs). However, concerns persist regarding bias in adherence to guideline-concordant care leading to disparities in implementing high-quality care for patients recovering from surgery for hip fracture. To assess disparities in the implementation of guideline-concordant care for patients after hip fracture surgery in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Hip Fracture (THF) Database. This cross-sectional study was conducted using the ACS-NSQIP THF database from 2016 to 2021 for patients aged 65 years and older with hip fractures undergoing surgical fixation. Care outcomes of racial and ethnic minority patients (including American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Pacific Islander, or multiple races and Hispanic ethnicity) were compared with non-Hispanic White patients via risk difference, stratified by care institution SHFP status. Modified Poisson regression was used to measure interactions. Statistical analysis was performed from November 2022 to June 2024. The primary outcomes of interest encompassed weight-bearing as tolerated (WBAT) on postoperative day 1 (POD1), venous thromboembolism (VTE) prophylaxis, bone-protective medication, and the presence of SHFP at the institution. Among 62 194 patients (mean [SD] age, 82.4 [7.3] years; 43 356 [69.7%] female) who met inclusion criteria and after multiple imputation, 11.2% (95% CI, 10.8%-11.5%) were racial and ethnic minority patients, 3.3% (95% CI, 3.1%-3.4%) were Hispanic patients, and 92.0% (95% CI, 91.7%-92.2%) were White. Receiving care at an institution with an SHFP was associated with improved likelihood of receiving guideline-concordant care for all patients to varying degrees across care outcomes. SHFP was associated with higher probability of being WBAT-POD1 (risk difference for racial and ethnic minority patients, 0.030 [95% CI, 0.004-0.056]; risk difference for non-Hispanic White patients, 0.037 [95% CI, 0.029-0.45]) and being prescribed VTE prophylaxis (risk difference for racial and ethnic minority patients, 0.066 [95% CI, 0.040-0.093]; risk difference for non-Hispanic White patients, 0.080 [95% CI, 0.071-0.089]), but SHFP was associated with the largest improvements in receipt of bone-protective medications (risk difference for racial and ethnic minority patients, 0.149 [95% CI, 0.121-0.178]; risk difference for non-Hispanic White patients, 0.181 [95% CI, 0.173-0.190]). While receiving care at an SHFP was associated with improved probability of receiving guideline-concordant care in both race and ethnicity groups, greater improvements were seen among non-Hispanic White patients compared with racial and ethnic minority patients. Older adults who received care at an institution with an SHFP were more likely to receive guideline-concordant care (bone-protective medication, WBAT-POD1, and VTE prophylaxis), regardless of race and ethnicity. However, the probability of receiving guideline-concordant care at an institution with an SHFP increased more for non-Hispanic White patients than racial and ethnic minority patients.

Comparison of Patient-Reported Outcomes for Immediate Unrestricted Weightbearing Versus Restricted Rehabilitation Protocols After Osteochondral Allograft Transplantation to the Distal Femur.

There is no standardized rehabilitation protocol after osteochondral allograft (OCA) transplantation surgery to the distal femur. The spectrum of recommendations includes restrictions to toe-touch weightbearing (TTWB) for 6 weeks and immediate weightbearing as tolerated (WBAT). The purpose of this study was to compare outcomes for immediate unrestricted WBAT to restricted TTWB after OCA transplantation to the distal femur. It was hypothesized that the immediate WBAT protocol would be noninferior to delayed, restricted TTWB. Retrospective cohort study. A total of 74 patients who underwent press-fit, dowel technique OCA transplantation to the femoral condyle(s) for contained (International Cartilage Repair Society grade 3-4) lesions were identified in the Metrics of Osteochondral Allograft multicenter database: 36 patients (18 women/18 men) who were prescribed TTWB were allocated to the control cohort and 38 patients (21 women/17 men) who were prescribed WBAT were allocated to the test cohort. Baseline characteristics were similar except for larger grafts in test patients (3.4 vs 2.7 cm2; P = .004) and higher body mass index (BMI) in control patients (27.8 vs 24.9 kg/m2; P = .01). Failure rates, final patient-reported outcome (PRO) scores, and PRO score changes from baseline were compared between the cohorts. Multiple regression was used to control for potential confounders and investigate noninferiority using minimal clinically important differences (MCIDs). The mean follow-up was 2 years (range, 1-5 years) in both cohorts. Both cohorts showed significant improvement in all PRO scores, with no significant between-group differences in failure rates, final PRO scores, or PRO changes from baseline. There were 3 cases of failure in each cohort (control cohort: allograft revision [n = 2], debridement [n = 1]; test cohort: chondroplasty [n = 2], conversion to total knee arthroplasty [n = 1]). Regression analysis showed that adjusted differences in final PRO scores based on weightbearing protocol were minor and less than MCIDs when controlling for age, sex, graft size, BMI, and allograft location. Analysis of the MCIDs with respect to the lower bounds of the confidence intervals indicated that WBAT was noninferior to TTWB with a reasonable degree of confidence (range, 84.1%-99.9% confidence). Results indicated that immediate unrestricted WBAT after OCA transplantation to the distal femur was equally safe and effective compared to restricted TTWB.

Surgical treatment of forefoot and midfoot fractures : Minimally invasive fixation of metatarsal fractures

Minimally invasive stabilization of metatarsal fractures to enable adequate fracture healing in acorrect position to restore anatomy and biomechanics of the foot. A.Dislocated diaphyseal and subcapital fractures of the second to fifth metatarsal (> 3 mm, > 10° dislocation). B.Fifth metatarsal fracture at the metadiaphyseal junction (Lawrence and Botte typeIII). High grade soft tissue damage or infection at the implant insertion site. A.Fluoroscopically assisted closed reduction and antegrade intramedullary fixation of diaphyseal and subcapital fractures of the second to fifth metatarsal. B.Fluoroscopically assisted wire-guided intramedullary screw fixation of fifth metatarsal fractures at the metadiaphyseal junction. A.Mobilization with partial weight bearing (20 kg) for 6weeks wearing astiff sole; implant removal under local anesthesia after 6-8weeks, followed by afree range of movement and weight-bearing as tolerated (WBAT). B.Early mobilization with weight-bearing as tolerated (WBAT); removal of the orthosis after 6weeks, implant removal optional. A.Antegrade nailing of subcapital and shaft fractures of metatarsalsII-V achieves good clinical results with low complication rates both when using prepared Kirschner wires or elastically stable intramedullary nails (ESIN). B.According to current literature, intramedullary screw osteosynthesis of proximal metatarsalV fractures of zoneII andIII according to Lawrence and Botte leads to faster bony healing with alower nonunion rate compared with conservative treatment. It is recommended especially, but not only, for active athletes.

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.

Immediate Unprotected Weightbearing vs 2 Weeks Nonweightbearing After Open Reduction Internal Fixation of Ankle Fractures.

Postoperative care protocols for ankle fracture surgery remain controversial with variability among care providers. This prospective controlled trial compared 12-week postoperative outcomes for immediate unprotected weightbearing (IMWB) vs nonweightbearing (NWB) for 2 weeks in a splint followed by weightbearing as tolerated (WBAT) in a boot after surgical fixation of selected low-energy ankle fractures without superior articular involvement. Eighty-seven patients undergoing surgical fixation of ankle fractures at a single level 1 trauma center were recruited according to specific criteria and enrolled by presentation date. The first 43 eligible patients were allocated to the control group, with NWB in a splint for 2 weeks followed by WBAT in a walker boot. The next 44 patients recruited were allocated to the IMWB group. The primary outcome was the Olerud-Molander score (OMAS). Secondary outcome measures included the Euroquol-5D (EQ5D) score and Work Productivity and Activity Impairment: Specific Health Problem (WPAI:SHP) scores, ankle range of motion (ROM), wound complications, time to return to work, radiograph measurements, and fracture reduction loss. In this perioperative-focused study, we collected data on patients until 12 weeks postoperation. The IMWB group had 5 superficial wound complications vs 1 in the control group. At 12 weeks, we found no difference in OMAS, EQ5D, WPAI:SHP scores, ROM, time to return to work, or radiographic measurements. In this short-term and relatively small prospective trial, we found more wound complications among patients treated with immediate unprotected weightbearing compared with patients treated with 2 weeks of NWB followed by protected weightbearing. Given the low incidence and small sample size, we do not know if these observed findings are generalizable. However, we also found no difference in functional outcomes at 12 weeks postoperation between these 2 groups. In light of that, we do not recommend IMWB after open reduction internal fixation of low-energy ankle fractures with plate and/or screw fixation. Level II, prospective controlled trial.

Assessing the content validity of the Manchester–Oxford Foot Questionnaire in surgically treated ankle fracture patients: a qualitative study

BackgroundRoughly 10% of fractures in adults are ankle fractures. These injuries are found in both sexes and present with different fracture characteristics. The treatment varies with the patients’ biology and fracture type, and the goals are to restore stability, prevent pain and maintain ankle function. Clinicians generally use outcomes like assessment of radiography, pain level, or function. The use of patient-reported outcome measures is increasing, and the Manchester–Oxford Foot Questionnaire (MOXFQ) has been shown to have good measurement properties when validated in patients with foot and ankle disorders. However, the instrument has not been validated for ankle fracture patients. This study aims to assess the content validity of the items in MOXFQ in surgically treated ankle fracture patients.MethodsA qualitative deductive design was used to investigate patients’ response process of the MOXFQ. Individual interviews were conducted using cognitive interviewing based on the theoretical framework of the 4-step model by Tourangeau. Adult patients that were surgically treated for an ankle fracture between four weeks and 18 months were purposively sampled, and interviews followed a semi-structured interview guide. The predetermined categories were comprehension, retrieval, judgement, and response.ResultsSeventeen respondents (65% females) were interviewed. Respondents’ age ranged from 27 to 76 years. Some of the respondents in the early recovery phase were limited by post-operative restrictions and did not find the items in the walking/standing domain relevant. Respondents that were allowed weight-bearing as tolerated (WBAT) were able to recall relevant information for most items. Respondents with time since surgery more than 12 months had less pain and remembered fewer relevant episodes in the recall period. Items in the social interaction domain contained ambiguous questions and were generally considered less important by respondents. The summary index score lacked important concepts in measuring overall quality of life.ConclusionsPain was a central concept in the post-operative recovery of ankle fracture patients. The MOXFQ-subscales for pain and walking/standing had acceptable content validity in patients that were allowed WBAT. The social interaction-subscale and the summary index score had insufficient content validity for this patient population.

Immediate Weight Bearing after Modified-Brostrom Reconstruction: A Retrospective Review of an Accelerated Rehab Protocol

Category: Ankle; Sports Introduction/Purpose: Majority of injuries to the anterior talofibular ligament (ATFL) will go on to heal with non-operative management. Nearly a third of these injuries, however, will go on to develop chronic pain and instability; in these cases, operative reconstruction is indicated. An anatomic modified Broström reconstruction has replaced a traditional tenodesis as the standard of care. This reconstruction is often limited by damage to the native tissue and the time required for ligamentous healing, restricting the benefits of early weight bearing. In order to maximize the benefits of early range-of-motion exercises and weight bearing while protecting the repair, a suture-tape augmented Broström procedure has been suggested. We hypothesized that a suture-tape augmented Broström procedure would allow early weightbearing while preventing early failure. Methods: A retrospective chart review of patients who underwent a suture-tape augmented Broström procedure from August, 2020 to January, 2023 was conducted. Our inclusion criteria consisted of MRI confirmation of ATFL injury, a positive anterior drawer, failure of non-operative management, and post-operative physical exam consisting of a single leg hop and single leg heel raise at six weeks. Patients who had concomitant cartilage injuries with allograft repair, posterior arthroscopic debridement, peroneal tendon repair, syndesmosis repair, or calcaneal osteotomies were excluded. All patients participated in our accelerated rehab protocol which included immediate post-operative weightbearing as tolerated (WBAT) in a boot for two weeks followed by WBAT in an ankle brace for four weeks. Physical therapy was initiated two weeks post-op. Our primary outcome was the ability of patients to perform a single leg hop and single leg heel rise at six weeks. Secondary outcomes included visual analog scores (VAS) and post-operative complications. Results: 128 patients met our inclusion criteria. Our mean follow up was 11 (range, 6-52) weeks. At 6 weeks postoperatively, 88 (90%) of the patients asked could perform a single-leg heel raise and 73 (80%) of the patients asked could perform a single-leg hop. The average VAS at the final follow up visit was 1.03+1.9 (range, 0-8). No patients required a revision surgery. Post-operative complications were peroneal or sural neuritis (6 patients) and persistent pain (4 patients). There was no difference in primary and secondary outcomes in patients who had concomitant cartilage injuries not treated with grafting. Male patients were more likely to be able to complete a single leg hop at 6 weeks postoperatively (p = .04). No difference was found amongst other demographic factors. Conclusion: This study demonstrated that a modified-Broström procedure with suture-tape augmentation allowed for immediate weight bearing without reconstruction failure. The vast majority of patients had an excellent functional outcome at six weeks post- operative with minimal complications being recorded. There were no cases of revision surgery, DVTs, post-operative infections, and no patients reported residual instability.

Effects of the COVID-19 Pandemic on Humeral Shaft Fracture Management and Its Outcomes.

Background and objective The coronavirus disease 2019 (COVID-19) pandemic necessitated a sudden and drastic shift in patient management throughout the healthcare system,to curb the spread of the disease and deal with resource limitations. Many surgical cases were canceled or delayed with only the most urgent and emergent cases taken up for treatment. It is unknown if and how these alterations affected patient outcomes. The purpose of this study was to compare time to fracture care and outcomes between patients treated for humeral shaft fractures prior to the COVID-19 pandemic and those treated during the pandemic. We hypothesized that the pandemic cohort would have a prolonged time to fracture care and worse outcomes than the pre-pandemic cohort. Materials and methods This was a retrospective cohort study performed within a single healthcare system. All humeral shaft fractures treated from March to June 2019 (pre-pandemic cohort) and March to June 2020 (pandemic cohort) were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes and ICD-10-CM codes as well as Current Procedural Terminology (CPT) codes. Data on demographics, fracture characteristics, treatment, and outcomes were collected via chart and radiograph review. Outcomes analyzed included time to being made weight-bearing as tolerated (WBAT), radiographic union, and final follow-up; range of motion (ROM) at radiographic union and final follow-up; and rate of complications. Results The pre-pandemic cohort (n=19) was significantly younger with a mean age of 29years than the pandemic cohort (n=17)with a mean age of 49years (p=0.010). Therewere no other significant differences in demographics, fracture characteristics, or treatment type between the groups. Time to fracture care was not significantly different in the pre-pandemic cohort (five days) versusthe pandemic cohort (four days). Time to being made WBAT, radiographic union, and final follow-up were not significantly different between thepre-pandemic(86, 113, and 98days) and the pandemic cohorts (77, 106, and 89.5 days). ROM measurements in abduction at radiographic union were significantly different between the cohorts: in the pre-pandemic cohort, 100% of patients reached greater than 160 degrees; in the pandemic cohort, only 16.7% of patients reached greater than 160 degrees (p=0.048). There was a non-significant decrease in the proportion of patients who achieved the maximal category of ROM measurements in forward elevation and extension at radiographic union and abduction, forward elevation, and extension at final follow-up, as well as a non-significant increase in visual analog scale (VAS) pain scores at final follow-up between cohorts. There were no significant differences in the rate of complications. Conclusions Despite limited resources, reduced operating room availability, and increased utilization of virtual visits due to the COVID-19 pandemic, patients with humeral shaft fractures may not have faced delays in fracture care or worse outcomes compared to the pre-pandemic period. The pandemic cohort may have experienced significantly decreased ROM compared to the pre-pandemic cohort, which may reflect the decreased availability of physical therapy services and overall decreased activity levels due to the quarantine orders. However, we could not identify any other significant differences in the type of treatment, pain, complications, or time to union.

Rehabilitation Variability Following Osteochondral Autograft and Allograft Transplantation of the Knee.

ObjectiveThe aim of this study is to assess the variability of postoperative rehabilitation protocols used by orthopedic surgery residency programs for osteochondral autograft transplantation (OAT) and osteochondral allograft transplantation (OCA) of the knee.DesignOnline postoperative OAT and OCA rehabilitation protocols from US orthopedic programs and the scientific literature were reviewed. A custom scoring rubric was developed to analyze each protocol for the presence of discrete rehabilitation modalities and the timing of each intervention.ResultsA total of 16 programs (10.3%) from 155 US academic orthopedic programs published online protocols and a total of 35 protocols were analyzed. Twenty-one protocols (88%) recommended immediate postoperative bracing following OAT and 17 protocols (100%) recommended immediate postoperative bracing following OCA. The average time protocols permitted weight-bearing as tolerated (WBAT) was 5.2 weeks (range = 0-8 weeks) following OAT and 6.2 weeks (range = 0-8 weeks) following OCA. There was considerable variation in the inclusion and timing of strength, proprioception, agility, and pivoting exercises. Following OAT, 2 protocols (8%) recommended functional testing as criteria for return to sport at an average time of 12.0 weeks (range = 12-24 weeks). Following OCA, 1 protocol (6%) recommended functional testing as criteria for return to sport at an average time of 12.0 weeks (range = 12-24 weeks).ConclusionA minority of US academic orthopedic programs publish OAT and OCA rehabilitation protocols online. Among the protocols currently available, there is significant variability in the inclusion of specific rehabilitation components and timing of many modalities. Evidence-based standardization of elements of postoperative rehabilitation may help improve patient care and subsequent outcomes.

Proximal Fifth Metatarsal Fractures: A Retrospective Study of 834 Fractures With a Minimum Follow-up of 5 Years.

Proximal fifth metatarsal fractures are common fractures. Treatment strategies have been debated. We wanted to investigate whether Lawrence and Botte's classification has prognostic value because of time to fracture union, and evaluate if weightbearing as tolerated (WBAT) and nonweightbearing (NWB) treatment strategy had effect on time to fracture union in nonoperatively treated fractures. Computerized database search, patients diagnosed between January 1, 2003, and December 31, 2015. We identified 834 fractures; 510 (61.2%) zone 1, 157 (18.8%) zone 2, and 167 (20.0%) zone 3. Most (94.4%) were treated nonoperatively; time to fracture union was 7.5 (SD 7.7), 7.7 (5.6), and 9.2 (8.1) weeks for zone 1, 2, and 3, respectively, which gave a significant longer time to union for zone 3 compared to zone 1 fractures (P = .04). There was no difference in time to fracture union when comparing WBAT and NWB for all fracture zones. Failure to union, defined as crossover to surgery and/or delayed union, was found in 13 (2.7%) zone 1, 5 (3.2%) zone 2, and 6 (3.8%) zone 3 fractures. Refracture during follow-up was found in 3 (0.6%) zone 1 and 14 (8.9%) zone 3 fractures. Proximal fifth metatarsal fractures have high union rates with nonoperative treatment. No difference in time to union could be found between WBAT and NWB treatment strategies for all fracture zones. We observed a significantly longer time to fracture union for zone 3 fractures compared to zone 1 fractures. Refracture occurs in a nonnegligible share of nonoperatively treated zone 3 fractures.

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

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

The Fifth Metatarsal Shaft Fracture Is Well Treated With Benign Neglect.

Background. Spiral fifth metatarsal fractures have been studied previously in professional dancers. However, little has been reported about outcomes of these injuries in the general population. The objective of this study was to examine patient demographics of those who sustain this injury and their functional outcomes, as stratified by treatment type. Methods. A total of 186 "nonprofessional dancer" patients with a fifth metatarsal fracture who were treated by one orthopaedic surgeon at our academic medical center were identified through chart review. All patients were allowed to weight bearing as tolerated (WBAT). Time to healing, persistence of pain, range of motion, and complications were recorded. Independent samples t tests, 1-way analysis of variance, and Fisher exact tests were used for analysis. Results. Thirty-seven of the 186 patients with fifth metatarsal fractures reviewed were identified as having a spiral fifth metatarsal fracture with appropriate follow-up. The cohort was 78.4% female with a mean age of 50.3 years. Twenty-two were initially treated in a controlled ankle motion (CAM) boot, 14 in a postoperative shoe, and 1 continued in their own shoes. All patients were allowed to WBAT. All fractures healed by a mean of 3.1 months. By the end of the follow-up period, 67.6% of patients had full range of ankle motion, with 5.4% reporting feeling stiff, 27.0% reporting mild persistent pain, and 2.7% reporting significant persistent pain. Conclusion. Fifth metatarsal shaft ("Dancer's") fractures occur within the general population, not only among professional dancers. Without operative fixation and regardless of nonoperative treatment selected, these fractures heal reliably and do so without clinically relevant complication.Level of Evidence: Level III: Retrospective comparative study.

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

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

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

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

Immediate weight-bearing is safe following lateral locked plate fixation of periprosthetic distal femoral fractures

PurposeThis study aimed to determine whether unrestricted weight-bearing as tolerated (WBAT) following lateral locking plate (LLP) fixation of periprosthetic distal femoral fractures (PDFFs) is associated with increased failure and reoperation, compared with restricted weight-bearing (RWB).Materials and methodsIn a retrospective cohort study of consecutive patients with unilateral PDFFs undergoing LLP fixation, patients prescribed WBAT were compared with those prescribed 6 weeks of RWB. The primary outcome measure was reoperation. Kaplan–Meier and Cox multivariable analyses were performed.ResultsThere were 43 patients (mean age 80.9 ± 11.7 years, body mass index 26.8 ± 5.7 kg/m2 and 86.0% female): 28 WBAT and 15 RWB. There were more interprosthetic fractures in the RWB group (p = 0.040). Mean follow-up was 3.8 years (range 1.0–10.4). Eight patients (18.6%) underwent reoperation. Kaplan–Meier analysis demonstrated no difference in 2-year survival between WBAT (80.6%, 95% CI 65.3–95.9) and RWB (83.3%, 95% CI 62.1–100.0; p = 0.54). Cox analysis showed increased reoperation risk with medial comminution (hazard ratio 10.7, 95% CI 1.5–80; p = 0.020) and decreased risk with anatomic reduction (hazard ratio 0.11, 95% CI 0.01–1.0; p = 0.046). Immediate weight-bearing did not significantly affect the risk of reoperation compared with RWB (relative risk 1.03, 95% CI 0.61–1.74; p = 0.91).ConclusionsLLP fixation failure was associated with medial comminution and non-anatomic reductions, not with postoperative weight-bearing. Medial comminution should be managed with additional fixation. Weight-bearing restrictions additional to this appear unnecessary and should be avoided.

Rehabilitation Variability Following Femoral Condyle and Patellofemoral Microfracture Surgery of the Knee.

To assess the variability of postoperative rehabilitation protocols used by orthopedic surgery residency programs for microfracture of femoral condyle and patellofemoral lesions of the knee. Online postoperative microfracture rehabilitation protocols from US orthopedic programs and the scientific literature were reviewed. A custom scoring rubric was developed to analyze each protocol for the presence of discrete rehabilitation modalities and the timing of each intervention. A total of 18 programs (11.6%) from 155 US academic orthopedic programs' published online protocols and a total of 44 protocols were analyzed. Seventeen protocols (56.7%) recommended immediate postoperative bracing for femoral condyle lesions and 17 (89.5%) recommended immediate postoperative bracing for patellofemoral lesions. The average time to permitting weight-bearing as tolerated (WBAT) was 6.1 weeks (range, 0-8) for femoral condyle lesions and 3.7 weeks (range, 0-8 weeks) for patellofemoral lesions. There was considerable variation in the inclusion and timing of strength, proprioception, agility, and pivoting exercises. For femoral condyle lesions, 10 protocols (33.3%) recommended functional testing prior to return to sport at an average of 23.3 weeks postoperatively (range, 12-32 weeks). For patellofemoral lesions, 4 protocols (20.0%) recommended functional testing for return to sport at an average of 21.0 weeks postoperatively (range, 12-32 weeks). A minority of US academic orthopedic programs publish microfracture rehabilitation protocols online. Among the protocols currently available, there is significant variability in the inclusion of specific rehabilitation components and timing of many modalities. Evidence-based standardization of elements of postoperative rehabilitation may help improve patient care and subsequent outcomes.

Return to activity following modified brostrom procedure with and without a semimembranosus allograft

Despite the modified Broström Procedure (MBP) being the gold standard for surgical treatment of chronic ankle instability (CAI), there is little data regarding factors that impact rehabilitation time. This retrospective analysis includes 67 consecutive Modified Broström Procedures (MBPs). Records were reviewed to define patient factors associated with increased time to return to activity (RTA). Of the 67 cases reviewed, 23 patients underwent reconstruction of the calcaneofibular (CFL) with a semimembranosus allograft in addition to repair of the anterior talofibular ligament (ATFL) with a suture tape. There were no significant demographic or clinical differences between these two groups. All patients had a minimum follow-up of 12 months. The mean age and body mass index (BMI) of the cohort was 44.7 years and 33.7 kg*m2, respectively, with a ratio of females to males of 2.35:1. Males began weight bearing as tolerated (WBAT) in a walking boot 1.08 weeks earlier than females (p = 0.053). Those with a BMI ≥ 35 kg/m2 RTA in normal shoe gear 0.50 weeks later (p = 0.443). Workers’ compensation cases were correlated with RTA (+0.431, p < 0.001). The number of completed physical therapy (PT) sessions had no significant correlation with time of return to activity (+0.063. p = 0.622). The post-operative complication rate was 7.5% (Five patients). No odds ratios were found to be statistically significant. Overall, these results suggest that semitendinosus allograft is safe, and corroborates prior evidence that worker's compensation cases are independently linked to a delayed return to activity. This data can potentially guide post-operative expectations and preparation of clinical trials.

Leg-Length-Evening Device Improves Balance in Patients Wearing a Controlled Ankle Motion Boot: A Multicenter Randomized Controlled Trial

Category:OtherIntroduction/Purpose:Patients are often made weight-bearing as tolerated (WBAT) in a controlled ankle motion (CAM) boot for the management of various foot and ankle conditions. The CAM boot causes a leg-length discrepancy (LLD) between the booted (longer) and contralateral (shorter) lower extremities. This discrepancy can potentially cause balance problems, undue strain on joints, and discomfort in patients. We hypothesized that a leg-length evening orthotic placed on the plantar aspect of the contralateral shoe improves balance among patients who are WBAT in a CAM boot.Methods:Patients made WBAT in a CAM boot were randomized to either the leg-length-evening orthotic intervention group or to a control group in which patients wore a normal shoe of their choice. Patients were followed for two weeks and asked a series of questions pertaining to balance and pain experienced at their knees, hips, and back. Balance was the primary outcome and was scored from 0 (no difficulty with balance) to 10 (great difficulty with balance).Results:Out of 107 subjects enrolled and randomized, 95 (88.8%) completed the study, satisfying the a priori sample size requirement of 94 patients. There were no differences in baseline characteristics between groups (p>0.05 for each). Intervention patients reported less difficulty with balance than control patients (intention-to-treat analysis: 2.0+-1.5 versus 3.2+-1.8, p=0.001; as-treated analysis: 2.1+-1.7 versus 3.0+-1.7, p=0.009). Intervention and control patients did not differ with respect to pain experienced at their knees, hips, or back, or in a composite total pain score (p>0.05 for each).Conclusion:This multicenter randomized controlled trial found that adding a limb-length-evening orthotic to the plantar aspect of the contralateral shoe in a patient that is WBAT in a CAM boot improves balance. The trial was powered to identify a difference in the primary outcome measure of balance and may have been insufficiently powered to identify differences in knee, hip, back, or total pain.

Immediate weight bearing as tolerated (WBAT) correlates with a decreased length of stay post intramedullary fixation for subtrochanteric fractures: a multicenter retrospective cohort study.

Subtrochanteric femur fractures associate with a relatively high complication rate and are traditionally treated operatively with a period of limited weight bearing. Transitioning from extramedullary to intramedullary implants, there are increasing biomechanical and clinical data to support early weight bearing. This multicenter retrospective study examines the effect of postoperative weight bearing as tolerated (WBAT) for subtrochanteric femur fractures. We hypothesize that WBAT will result in a decreased length of stay (LOS) without increasing the incidence of re-operation. This study assesses total LOS and postoperative LOS after intramedullary fixation for subtrochanteric fractures between postoperative weight bearing protocols across 6 level I trauma centers (n = 441). Analysis techniques consisted of multivariable linear regression and nonparametric comparative tests. Additional subanalyses were performed, targeting mechanism of injury (MOI), Winquist-Hansen fracture comminution, 20-year age strata, and injury severity score (ISS). Total LOS was shorter in WBAT protocol within the overall sample (7.4 vs 9.7days; p < 0.01). Rates of re-operation were similar between the two groups (10.6% vs 10.5%; p = 0.99). Stratified analysis identified patients between ages 41-80, WH comminution 2-3, high MOI, and ISS between 6-15 and 21-25 to demonstrate a significant reduction in LOS as a response to WBAT. Animmediate postoperative weight bearing as tolerated protocol in patients with subtrochanteric fractures reduced length of hospital stay with no significant difference in reoperation and complication rates. If no contraindication exists, immediate weight bearing as tolerated should be considered for patients with subtrochanteric femur fractures treated with statically locked intramedullary nails. Therapeutic Level III.

Effect of Leg Length-Evening Device on Perceived Balance in Patients Wearing a Controlled Ankle Motion Boot.

Background:Patients are often made weightbearing as tolerated (WBAT) in a controlled ankle motion (CAM) boot for the management of various foot and ankle conditions. The CAM boot causes a leg length discrepancy (LLD) between the booted (longer) and contralateral (shorter) lower extremities. This discrepancy can potentially cause balance problems, undue strain on joints, and discomfort in patients. We hypothesized that a leg length–evening orthotic placed on the plantar aspect of the contralateral shoe improves balance among patients who are WBAT in a CAM boot.Methods:Patients made WBAT in a CAM boot were randomized to either the leg length–evening orthotic intervention group or to a control group in which patients wore a normal shoe of their choice. Patients were followed for 2 weeks and asked a series of questions pertaining to balance and pain experienced at their knees, hips, and back. Balance was the primary outcome and was scored from 0 (no difficulty with balance) to 10 (great difficulty with balance). Of 107 subjects enrolled and randomized, 95 (88.8%) completed the study, satisfying the a priori sample size requirement of 94 patients. There were no differences in baseline characteristics between groups (P > .05 for each).Results:Intervention patients reported less difficulty with balance than control patients (intention-to-treat analysis: 2.0±1.5 vs 3.2±1.8, P = .001; as-treated analysis: 2.1±1.7 vs 3.0±1.7, P = .009). Intervention and control patients did not differ with respect to pain experienced at their knees, hips, or back, or in a composite total pain score (P > .05 for each).Conclusion:This multicenter randomized controlled trial found that adding a limb length–evening orthotic to the plantar aspect of the contralateral shoe in a patient that is WBAT in a CAM boot improved patient-reported self-assessment of balance. The trial was powered to identify a difference in the primary outcome measure of balance and may have been insufficiently powered to identify differences in knee, hip, back, or total pain.Level of Evidence:Level II, prospective comparative study.