Weight-bearing Status Research Articles

The correlation between osteoarthritis stage and the effect of the lateral wedge insole for 3 months on medial meniscus extrusion in the knee joint

BackgroundMedial meniscus extrusion (MME) leads to symptomatic knee osteoarthritis (OA) due to increased mechanical stress. MME increases with weight-bearing, and the difference in MME between non-weight-bearing and weight-bearing status (ΔMME) is a factor that causes greater MME. The lateral wedge insole (LWI) is an ideal approach for decreasing the amount of ΔMME associated with the reduction of medial loading stress in the early stage of knee OA. However, the effect of the LWI for 3 months on the ΔMME and its response to OA stage have not been elucidated. ObjectiveTo investigate the effects of the LWI for 3 months on MME and the ΔMME in each stage of OA. MethodsParticipants were divided into three groups: no intervention with the LWI (control group; n = 9) and intervention with the LWI in early OA (early OA group: Kellgren–Lawrence (K/L) stage = 2, n = 17) and late OA (late OA group: K/L stage > 2, n = 13). MME was evaluated using ultrasound, and the ΔMME was obtained as the difference in MME from non-weight-bearing and weight-bearing conditions. These measurements were performed at two time points: the initial office visit as a baseline and post-3 months. ResultsThe weight-bearing MME and ΔMME values post-3 months were significantly decreased compared with those at baseline in the early OA group but not in the control or late OA groups. ConclusionsThe use of the LWI for 3 months decreased weight-bearing MME and ΔMME values, and its effectiveness was more pronounced in the early stage of knee OA.

Investigating the Use of Denosumab in the Treatment of Acute Charcot Neuroarthropathy

Charcot neuroarthropathy is a devastating condition, most commonly affecting poorly controlled diabetic patients with peripheral neuropathy. Pharmacological options for the condition are currently limited. The purpose of this study was to investigate the potential of Prolia® (denosumab) as a safe and feasible option in the treatment of acute Charcot neuroarthropathy. A total of 7 consecutive subjects were enrolled and followed for 1 year. Subjects received a single one-time injection of denosumab 60 mg. Subjects also received standard of care treatment, which included total contact casting, restricted weightbearing status, and biweekly office visits until normalization of the skin temperature gradient. Overall, the pharmaceutical treatment was generally well-tolerated. One subject developed a diabetic foot infection with cellulitis of the contralateral lower extremity, which occurred following the 6-month follow-up visit and which resolved with oral antibiotics One subject identified transient muscle pain in the same upper extremity which received the injection. Subjects were found to exit the acute phase of the condition at an average of 52.00 ± 17.89 days after their injection, which was defined by normalization of skin temperature to within 2°C of the contralateral foot. Treatment of acute Charcot neuroarthropathy with denosumab was well-tolerated in this open-label, pilot study. The clinical outcomes suggest that the medication may be efficacious, though a larger sample size would be needed to confirm these preliminary results. An adequately-powered, randomized, controlled study may be an appropriate follow-up.

Does immediate weight-bearing following intramedullary tibial nailing affect union rates? The results from a single UK trauma unit

Introduction Extra-articular diaphyseal tibial fractures are a common injury and are often treated with intramedullary nailing (IMN). Weight-bearing (WB) of simple tibial fractures treated with an IMN immediately as pain allows is now standard practice. Our aim was to assess the impact of varied WB on fracture union following IMN of diaphyseal tibia fractures. Methods We conducted a retrospective cohort study of tibial fractures treated with IMN in our department between 2012-2017. WB status was recorded in the post-operative note and subsequently reviewed in the patients’ follow-up appointments. Patients were divided in three groups; Group I: immediate full-WB, Group II: non-WB for 6 weeks and Group III: 2 weeks non-WB, 4 weeks increasing partial-WB and full-WB at 6 weeks. Radiographic union score for tibial fractures (RUST) of ≥10 at a painless fracture site was considered as evidence of fracture union. Results 92 patients with comparable pre-operative demographics [mean age 40 y (16-88)] were included. The median union time in weeks for each group was: Group I 17.3, Group II 21.7 and Group III 19.5 (F 1.09, p 0.34). Survival analysis and log rank test did not show any difference in union times between the three groups (x2 1.1, p 0.57). 12 delayed unions were identified across all groups. Multiple logistic regression identified three factors that could increase the rate of delayed union – non-WB, smoking and IMN size 11/12 mm - however the results were not statistically significant. Conclusion Immediate post-operative WB does not adversely affect union time in statically locked IMNs. In fact, although our data show no statistically significant difference in fracture healing between the three groups, full WB seems to decrease overall time to union. In conclusion, we could suggest that full WB after IMN in patients with AO 42-A/B type fractures is safe practice.

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.

What Predicts Health-Related Quality of Life for Patients With Displaced Femoral Neck Fractures Managed With Arthroplasty? A Secondary Analysis of the HEALTH Trial.

Total hip arthroplasty (THA) has been argued to improve health-related quality of life (HRQoL) and function in femoral neck fracture patients compared with hemiarthroplasty (HA). The HEALTH trial showed no clinically important functional advantages of THA over HA. The current analysis explores factors associated with HRQoL and function in this population. Using repeated measures regression, we estimated the association between HRQoL and function [Short Form-12 (SF-12) physical component score (PCS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function score] and 23 variables. THA as compared to monopolar HA, but not bipolar HA, was more likely to improve PCS scores (adjusted mean difference [AMD] 1.88 points, P = 0.02), whereas higher American Society of Anesthesiologists score (AMD -2.64, P < 0.01), preoperative use of an aid (AMD -2.66, P < 0.01), and partial weight-bearing status postoperatively (AMD -1.38, P = 0.04) demonstrated less improvement of PCS scores over time. THA improved WOMAC function scores over time compared with monopolar HA (but not bipolar HA) (AMD -2.40, P < 0.01), whereas higher American Society of Anesthesiologists classification (AMD 1.99, P = 0.01) and preoperative use of an aid (AMD 5.39, P < 0.01) were associated with lower WOMAC function scores. Preoperative treatment for depression was associated with lower functional scores (AMD 7.73, P < 0.01). Patients receiving THA are likely to receive small and clinically unimportant improvements in health utility and function compared with those receiving monopolar HA and little improvement compared with those receiving bipolar HA. Patient-specific characteristics seem to play a larger role in predicting functional improvement among femoral neck fracture patients. Prognostic Level II.

Variable Lower Limb Alignment of Clinical Measures With Digital Photographs and the Footscan Pressure System

This study examines the effect of the lower limb misalignment and its possible compensatory effect on plantar pressure in a normal population. The aim of this paper is to present a structured method for the analysis of posture and its changes using a standardized digital photography technique and plantar pressure measuring device. Cohort. Laboratory. A total of 200 adult volunteers between 18 and 22 years of age who had no current symptoms of pain and foot or ankle pathology participated in the study. The gold standard measure of lower limb alignment with weight-bearing status is the mechanical axis and their angles using Image J software. Structural and functional measurements of the same foot were taken using a plantar pressure measuring device. In this study, 5 alignment (thigh, knee, leg, ankle, and foot) characteristics were measured on the lower limb using the 2 techniques, and, additionally, the foot contact area, peak pressure, foot axis, rearfoot angle, and subtalar joint flexibility score were analyzed in 10 different regions of the foot. This study has shown a reasonable correlation between digitalized measurements and plantar pressures values. Quadriceps angle affected midfoot impulse, foot axis angle, subtalar joint minimum angle, and rearfoot angle positively. Subtalar joint flexibility scores were analyzed in 10 different regions of the foot. There was a positive correlation between rearfoot angle and quadriceps angle (P = .009, r = .261). Results of both methods show that they endorse each other. The posture of the standing feet may have influence on lower limb alignment. Currently, there are no studies carried out by using digital photogrammetry and foot scan. The authors claim that patient-friendly digital photogrammetry would have a positive contribution to the monitoring of patients, even including new ones in the treatment programs, reducing any possible loss in the personal and national economy.

Optimizing Discharge Summaries: A Multispecialty, Multicenter Survey of Primary Care Clinicians.

Patient care in the United States has become increasingly more fragmented, and the discharge summary serves as a critical tool for transmitting information on a patient's hospital admission to the primary care clinician. Some guidelines regarding how to write discharge summaries exist, but few are focused on prioritizing content that is most important to optimize a patient's transition of care. We conducted a national survey across various medical primary care specialties, including trainees and advanced practice providers, to understand the priorities of primary care clinicians. We distributed the survey to 2184 clinicians affiliated with 8 large academic institutions. Our response rate was 21%. Hospital course, discharge diagnoses, medication reconciliation, and follow-up sections were ranked as the most important categories with a 95.5% concordance rate among surveyed institutions. The least important sections were contact numbers for inpatient clinicians, ancillary services, weight-bearing status, and wound care. Similar themes were also identified via consensus review of the free-texted comments, adding that discharge summary style was also important. Other identified barriers to high-quality transition of care are both the limited time primary care clinicians can spend reviewing discharge summaries and lack of adequate communication between hospitalists and the outpatient clinician. High-yield content should be presented at the beginning of the discharge summary and conveyed in a brief, succinct manner to ensure maximal utility of the document as a transition of care tool.

Impact of Early Weight Bearing on Outcomes after Open Reduction and Internal Fixation of Trimalleolar Ankle Fractures

Category:Ankle; TraumaIntroduction/Purpose:There is a current trend to allow earlier weight-bearing of unstable ankle fractures after fixation. This study offers a unique comparison of early (EWB) versus late weight-bearing (LWB) in operatively stabilized trimalleolar ankle fractures. The purpose of this study was to evaluate union rates, clinical outcomes and complications in patients managed with EWB versus LWB.Methods:We performed a retrospective review of 185 patients with trimalleolar ankle fractures who underwent surgical stabilization. Fixation of the posterior malleolus and weight-bearing status were determined by surgeon preference. EWB was defined as ≥3 weeks and LWB was defined as >3 weeks. Patients were evaluated for fracture union and implant failure. Complications and clinical outcomes included ambulatory status, infection rate and return to surgery.Results:There were 47 (25.4%) patients in the EWB group and 138 (74.6%) in the LWB group. There were 7 nonunions, 1 (14.3%) in the EWB and 6 (85.7%) in the LWB group. Seventy-two (38.9%) posterior malleolar fractures were operatively stabilized which did not affect union rates. Syndesmotic fixation was required in 12.5% of patients despite posterior malleolar stabilization. Syndesmotic fixation increased union rate 2.5 times. Deep infection and open fracture decreased union. There was no difference in implant failure, union rate, infection or return to surgery between groups.Conclusion:No deleterious effect of EWB of operatively treated trimalleolar ankle fractures were found with regards to union, implant failure, infection or reoperation. Syndesmotic fixation may offer an advantage to posterior malleolar fixation with improved union rates.

Review of Variability in Rehabilitation Protocols after Lateral Ankle Ligament Surgery

Category:Ankle; SportsIntroduction/Purpose:Ankle sprains are one of the most common athletic injuries. If a patient fails to improve through conservative management, surgery is an option to restore ankle stability. The purpose of this study is to analyze the variability across rehabilitation for patients undergoing lateral ankle ligament repair, reconstruction, or suture tape augmentation.Methods:26 protocols were found. Inclusion criteria was protocols for ankle ligament surgery. Protocols for nonoperative care were excluded. A rubric was created to analyze weightbearing, range of motion (ROM), immobilization, single leg exercises, return to running, and return to sport (RTS).Results:There was variability especially in recommendations for immobilizing brace, partial and full weigh bearing, specific ROM movements of the ankle, and return to single leg exercise and running. For repair and reconstruction, none of these categories had greater than 60% agreement. 100% (12/12) of repair and 86% (12/14) of reconstruction protocols recommended no ROM postoperatively, and 86% (6/7) repair and 78% (11/14) reconstruction recommended no weightbearing postoperatively, making postoperative ROM and weightbearing status the most consistent aspects across protocols. Suture tape augmentation protocols generally allowed rehabilitation on a quicker timeline with full weightbearing by week 4-6 in 100% (3/3) of protocols and full ROM by week 8-10 in 66% (2/3). RTS was consistent in repair protocols (100% at week 12-16).Conclusion:ROM was variable across protocols and did not always match up with supporting literature. Return to sport was likely to correlate between protocols and the literature. Weightbearing was consistent between protocols. The variability between programs demonstrated the need for standardization of rehabilitation.

Asymmetric Lambda Sign on Axial Weightbearing CT Scans of the Foot: An Indicator to Aid in the Diagnosis of Subtle Lisfranc Instability?

Category:Trauma; Midfoot/ForefootIntroduction/Purpose:Subtle Lisfranc instability, a spectrum of conditions resulting from trauma of individual structures within the Lisfranc ligamentous complex (LLC) including the dorsal- (DLL), interosseous- (ILL), and plantar Lisfranc ligaments (PLL) remain challenging to effectively diagnose. The current standard to asses these injuries is through bilateral weightbearing radiography. However, weight bearing computed tomography (WBCT), which provides a clearer visualization of osseous structures, joint spaces, and instability could also be utilized for evaluation. This study aims to define and report the occurrence rate of an ‘asymmetric lambda sign’ observed on axial WBCT imaging secondary to simulated purely ligamentous Lisfranc injuries of various severities subjected to increasing magnitudes of weightbearing conditions. It is hypothesized that this sign will be a reliable aid in detecting subtle Lisfranc instability, clinically.Methods:The asymmetric lambda sign was assessed on 24 match-paired cadaveric legs (mean age, 46.0 +- 14.8 years; mean weight, 80.2 +- 17.4 kg; mean body mass index, 25.3 +- 4.2 kg/m2). Dissection groups were described as follows: control intact LLC (group 1), dissection of the DLL (group 2), dissection of the DLL and ILL (group 3), dissection of the DLL, ILL, and PLL (group 4). After each dissection, CT scans were acquired in non- (NWB, 0 kg), partial- (PWB, 40 kgs), and full-weightbearing (FWB, 80 kgs) conditions. In a standardized axial view, the lambda sign was appreciated by visualizing the joint spaces between the medial cuneiform and the second metatarsal base (C1-M2), the medial and middle cuneiform (C1-C2), and the second metatarsal base and middle cuneiform (M2-C2). The asymmetric lambda sign was defined by a widening of the C1-M2 joint space relative to the C1-C2 or M2-C2 joint space (Fig).Results:The asymmetric lambda sign was observed in 25.6% (221/864) of all studies. This sign was not found in any intact specimens regardless of the weightbearing status. In group 2, this sign was observed in 4.2% of NWB, 15.3% of PWB, and 16.7% of FWB conditions. With the DLL and ILL dissected, simulating a more developed subtle LLC injury (group 3), this sign was observed in 15.3%, 27.8%, and 38.9% in NWB, PWB and FWB conditions, respectively. Additionally, the fully dissected specimens (group 4), demonstrated this specific sign in 33.3%, 72.2%, and 83.3% in NWB, PWB, and FWB conditions, respectively. The inter- and intra- observer reliability was calculated to a kappa value of .843 and .912.Conclusion:An asymmetric lambda sign viewed through axial WBCT imaging is a reliable indicator in the diagnosis of a complete Lisfranc ligamentous injury with secondary joint instability in partial and full weightbearing conditions as demonstrated using a cadaveric model. Clinically, this simple sign can be utilized as an aid to accurately evaluate and diagnose patients presenting with subtle Lisfranc instability.

Clinical and radiographic outcomes following retrograde SIGN fin nailing for femoral shaft fractures.

Purpose:The Surgical Implant Generation Network (SIGN) intramedullary nail was designed for use in resource limited settings which often lack fluoroscopy, specialized fracture tables, and power reaming. A newer design iteration, the SIGN Fin nail, was developed to further simplify retrograde femoral nailing by making proximal interlocking screw placement unnecessary. Instead, the leading end of the Fin nail achieves stability through an interference fit within the proximal femoral canal. While the performance of the traditional SIGN nail has been reported previously, no large series has examined long-term clinical and radiographic outcomes of femoral shaft fractures treated with the SIGN Fin nail.Methods:The SIGN online surgical database was used to identify all adult femoral shaft fractures treated with the SIGN Fin nail since its introduction. All patients with minimum 6 month clinical and radiographic follow-up were included in the analysis. Available demographic, injury, and surgical characteristics were recorded. Fracture alignment was evaluated on final follow-up radiographs using a previously validated on-screen protractor tool. Coronal and sagittal plane alignment measurements were recorded as deviation from anatomic alignment (DFAA), with units in degrees. Fracture healing was assessed on final follow-up radiographs, with union defined as any bridging callus and/or cortical remodeling across one cortex on orthogonal views. Clinical outcomes available in the database included knee range of motion (ROM) greater than 90° and weight-bearing status at final follow-up. Clinical and radiographic outcomes were then compared between patients with united and nonunited fractures.Results:The database query identified 249 femoral shaft fractures stabilized with the Fin nail in 242 patients who had minimum 6 month clinical and radiographic follow-up. Final follow-up radiographs were performed at an average of 48 weeks postoperatively. Average coronal and sagittal plane alignment measured on final follow-up radiographs were 2.18° and 2.58°, respectively. The rate of malalignment (DFAA > 10° in either plane) at final follow-up was 6%. Two hundred twenty-nine fractures (92%) were united at final follow-up. Overall, 209 (84%) of patients achieved full weight bearing and 214 (86%) achieved knee ROM >90° at final follow-up. Compared to patients with united fractures, those with nonunion were less likely to achieve full weight bearing (20% vs 90%, P < .001) and knee ROM >90° (30% vs 91%, P < .001). There was no significant difference in mean DFAA between united and nonunited fractures in the coronal (2.1° vs 3.8°, P = .298) or sagittal (2.5° vs 3.5°, P = .528) planes.Conclusion:The SIGN Fin nail achieves satisfactory radiographic alignment and clinical outcomes at minimum 6 month follow-up. The overall union rate is comparable to that achieved with the standard SIGN nail. Ease of implantation makes the Fin nail an attractive option in resource-limited settings.

Are Weightbearing Restrictions Required After Microfracture for Isolated Chondral Lesions of the Knee? A Review of the Basic Science and Clinical Literature.

A strict rehabilitation protocol is traditionally followed after microfracture, including weightbearing restrictions for 2 to 6 weeks. However, such restrictions pose significant disability, especially in a patient population that is younger and more active. An extensive literature review was performed through PubMed and Google Scholar of all studies through December 2018 related to microfracture, including biomechanical, basic science, and clinical studies. For inclusion, clinical studies had to report weightbearing status and outcomes with a minimum 12-month follow-up. Clinical review. Level 3. Review of biomechanical and biology studies suggest new forming repair tissue is protected from shear forces of knee joint loading by the cartilaginous margins of the defect. This margin acts as a shoulder to maintain axial height and allow for tissue remodeling up to at least 12 months after surgery, well beyond current weight bearing restriction trends. A retrospective case-control study showed that weightbearing status postoperatively had no effect on clinical outcomes in patients who underwent microfracture for small chondral (<2 mm2) defects. In fact, 1 survey showed that many orthopaedic surgeons currently do not restrict weightbearing after microfracture. This clinical literature review suggests that weightbearing restrictions may not be required after microfracture for isolated tibiofemoral chondral lesions of the knee. C.

Risk Factors for Arthrofibrosis in Tibial Spine Fractures: A National 10-Site Multicenter Study

Objectives:To identify risk factors for developing arthrofibrosis after TSF treatment.Methods:This was a retrospective, multi-center study across ten institutions of 448 patients <25 years old who presented to care with a tibial spine fracture between 1/2000 and 2/2019. Patient records were reviewed for a multitude of pre-operative, intra-operative, and post-operative characteristics. Patients were then separated into two cohorts based on if they suffered from post-treatment arthrofibrosis.Results:Chart review demonstrated that 43 (9.6%) of the patients suffered from post-treatment arthrofibrosis. There were no demographic differences observed between the two groups. However, based on MRIs at the time of injury, distal femoral and proximal tibial growth plates were more frequently closed in the arthrofibrosis group (17.6% vs 4.4%, p=0.023 for both comparisons). Additionally, there was no difference in Meyers & McKeever (MM) classification (p=0.597). All arthrofibrosis patients received operative treatment (p=0.003), though there was no difference in fixation technique (p=0.734). Intraoperatively, a higher number of screws were used in the arthrofibrosis group (p=0.002) with the placement of hardware more likely to be epiphyseal (p=0.007). Other operative parameters including number of sutures were not different. Post-operatively, arthrofibrosis patients were more likely to have been immobilized in a cast (p<0.001) with no difference observed for weight-bearing status. After multivariate regression, screw number (OR 8.9, CI 1.9-41.7, p=0.005) and immobilization in a cast (OR 7.8, CI 1.0-60.4, p=0.049) remained significant predictors of post-treatment arthrofibrosis.Conclusion:This serves as the largest study of tibial spine fractures to analyze risk factors for the development of post-treatment arthrofibrosis. Our study demonstrates that pre-operative factors were largely similar between groups, but that intra-operative decisions, including the number of screws used for fixation and placement of hardware in relation to the physis, were significant predictors of post-treatment arthrofibrosis. These findings may influence operative decision-making in tibial spine fracture patients. Additionally, post-operative immobilization in a cast should be avoided given the high risk of arthrofibrosis.Table 1.Characteristics of patients with post-operative arthrofibrosis Arthrofibrosis (N=43) No Arthrofibrosis (N=405) P-value Demographic Age (years)11.112.00.065Male: Female ration24:19282:1230.064BMI20.220.40.824 Injury Sports-related (%)13 (30.2)205 (50.4) 0.012 MM classification III/IV20 (64.5)134 (59.6)0.597Concomitant ACL injury (%)5 (22.7)46 (21.6)0.902Delay to surgery (days)24.224.30.989 Operative Received surgery (%)43 (100.0)325 (78.5) 0.003 Operative time (min)142.0123.90.209Treatment type (%) ARIF36 (83.7)269 (82.8)0.734ORIF7 (16.3)45 (13.8) Screws (%)22 (51.2)114 (35.5) 0.046 Number of Screws1.81.4 0.002 Screw/Suture Placement (%) 0.005 Transphyseal5 (17.9)94 (44.5) 0.007 Epiphyseal23 (82.1)117 (55.5) Post-operative 41 (97.6)305 (97.8) Immobilized21 (51.2)72 (23.7)0.955Cast immobilization16 (39.0)208 (68.2) <0.001 Non-weightbearing11 (34.4)72 (25.4)0.277

A prospective comparative study of Proximal Femoral Nailing Anti-rotation (PFNA) and Sliding Hip Screw (SHS) for Per-trochanteric Femur Fracture

Objectives: To determine the functional outcome, operative risks, rate of union, and complication in Per-trochanteric Fracture fixed with PFNA and SHS.&#x0D; Material and Methods: The present study has been conducted at Shalamar Medical and Dental College Lahore from January 2018 to December 2018.40 patients with per-trochanteric femur fracture treated with proximal femoral nailing anti-rotation (PFNA) and Sliding hip screw (SHS) were enrolled in our study.20 patients were treated by PFNA and 20 patients by SHS. Timing of surgery, mobilization status, hospital stay, infection, weight-bearing status, radiological union, complications both technical and implant-related, amount of blood loss(ml), C ARM Exposures, and Harris hip score at the end of 6 months were recorded.&#x0D; Results: Union was better in the PFNA group (95%) as compared to the SHS group (85%). Complication rate, hospital stay, surgery timing, and requirement of revision surgery were more in the SHS group. The functional outcome was better in the PFNA group as compared to the SHS group.&#x0D; Conclusion: From our study, we concluded that PFNA is a better alternative than SHS in terms of higher union rates, low complication rates, and better functional outcomes.&#x0D;

Review of Variability in Rehabilitation Protocols after Lateral Ankle Ligament Surgery

Ankle sprains are one of the most common athletic injuries. If a patient fails to improve through conservative management, surgery is an option to restore ankle stability. The purpose of this study was to analyze and assess the variability across different rehabilitation protocols for patients undergoing either lateral ankle ligament repair, reconstruction, and suture tape augmentation. Using a web-based search for published rehabilitation protocols after lateral ankle ligament repair, reconstruction, and suture tape augmentation, a total of 26 protocols were found. Inclusion criteria were protocols for post-operative care after an ankle ligament surgery (repair, reconstruction, or suture tape augmentation). Protocols for multi-ligament surgeries and non-operative care were excluded. A scoring rubric was created to analyze different inclusion, exclusion, and timing of protocols such as weight-bearing, range of motion (ROM), immobilization with brace, single leg exercises, return to running, and return to sport (RTS). Protocols inclusion of different recommendations was recorded along with the time frame that activities were suggested in each protocol. Twenty-six protocols were analyzed. There was variability across rehabilitation protocols for lateral ankle ligament operative patients especially in the type of immobilizing brace, time to partial and full weigh bearing, time to plantar flexion, dorsiflexion, eversion and inversion movements of the ankle, and return to single leg exercise and running. For repair and reconstruction, none of these categories had greater than 60% agreement between protocols. All (12/12) repair, internal brace, and unspecified protocols and 86% (12/14) of reconstruction protocols recommended no ROM immediately postoperatively. Eighty-six percent (6/7) of repair and 78% (11/14) of reconstruction protocols recommended no weight-bearing immediately after surgery, making post-operative ROM and weight-bearing status the most consistent aspects across protocols. Five protocols allowed post-operative weight-bearing in a cast to keep ROM restricted. Sixty-six percent (2/3) of suture tape augmentation protocols allowed full weight-bearing immediately post-operatively. Suture tape augmentation protocols generally allowed rehabilitation to occur on a quicker time-line with full weight-bearing by week 4-6 in 100% (3/3) of protocols and full ROM by week 8-10 in 66% (2/3) protocols. RTS was consistent in repair protocols (100% at week 12-16) but varied more in reconstruction. There is significant variability in the post-operative protocols after surgery for ankle instability. ROM was highly variable across protocols and did not always match-up with supporting literature for early mobilization of the ankle. Return to sport was most likely to correlate between protocols and the literature. Weight-bearing was consistent between most protocols but requires further research to determine the best practice. Overall, the variability between programs demonstrated the need for standardization of rehabilitation protocols.

Management of Lateral Thigh Pain following Cephalomedullary Nail: A Technical Note

Peritrochanteric hip fractures are most commonly treated with proximal femoral fixation devices, such as a cephalomedullary nail or sliding hip screw. As usage rates increase for these fixation devices, complications from their insertion are becoming more prevalent. Lateral hip pain from proximal locking device insertion and prominence continues to be one of the most frequent complaints regarding hardware irritation following this surgical procedure. Conservative treatment options for this complaint include local corticosteroid injection and physical therapy, although once these treatments have been exhausted, surgical intervention may be recommended. This has generally been managed previously with implant removal, although studies have shown associated femoral neck fractures after removal even with the prescribed protected postoperative weight bearing. Additionally, in certain situations (e.g., when the nail is placed for prophylactic treatment), its removal is contraindicated. The purpose of this manuscript is to describe an alternative treatment option that would limit morbidity, and the need for proximal locking device or implant removal by excising the portion of the iliotibial band causing hip irritation at the level of the proximal locking device, while leaving the retained implant in place. This surgical option would allow most patients to return to their pre-operative weight-bearing status immediately following surgery without the need for additional postoperative precautions.

Non-weightbearing compared with weightbearing x-rays in hallux valgus decision-making

ObjectiveTo report the effect of weightbearing x-ray imaging on clinical decisions in hallux valgus. Weightbearing (WB) x-ray is standard imaging for symptomatic hallux valgus (HV). In our clinical practice, often patients are presenting with non-weightbearing (NWB) x-rays. Repeated imaging requires additional radiation, justified only if expected to benefit patient’s treatment. In this study, the influence of WB status on radiological HV parameters and on clinical decisions was analyzed.MethodsIn the dataset of WB and NWB x-rays, the hallux valgus (HVA) and intermetatarsal angle (IMA) were measured and differences analyzed. Clinical decisions for 10 x-ray pairs were studied among 40 respondents.ResultsThe WB and NWB HVA difference ranged − 16 to 16° (p < 0.001) and IMA − 3.4 to 5.8° (p < 0.001). In only 45% of cases, the decisions based on NWB and WB imaging were consistent (kappa (95% CI) = 30.0 (23.7–36.3)).ConclusionsClinical decisions based on WB and NWB radiographs vary significantly. NWB films overestimate early and underestimate advanced HV deformity. Repeating radiographs is justified in patients presenting with NWB radiographs of symptomatic HV.

RISK FACTORS FOR ARTHROFIBROSIS IN TIBIAL SPINE FRACTURES: A NATIONAL 10-SITE MULTICENTER STUDY

Background:Tibial spine fractures are common pediatric injuries with similar mechanism of injury to anterior cruciate ligament tears. Post-operative arthrofibrosis remains the most common complication following treatment of this injury, and many patients require subsequent manipulation under anesthesia. Several prior studies have examined risk factors for the development of arthrofibrosis, but with small patient populations and varying reported predictors. Therefore, our objective was to identify risk factors for arthrofibrosis in the largest known cohort of pediatric tibial spine patients.Hypothesis/Purpose:Identify risk factors for developing arthrofibrosis after TSF treatment.Methods:This was a retrospective, multi-center study across ten institutions of 448 patients <25 years old who presented to care with a tibial spine fracture between 1/2000 and 2/2019. Patient records were reviewed for a multitude of pre-operative, intra-operative, and post-operative characteristics. Patients were then separated into two cohorts based on if they suffered from post-treatment arthrofibrosis.Results:Chart review demonstrated that 43 (9.6%) of the patients suffered from post-treatment arthrofibrosis. There were no demographic differences observed between the two groups. However, based on MRIs at the time of injury, distal femoral and proximal tibial growth plates were more frequently closed in the arthrofibrosis group (17.6% vs 4.4%, p=0.023 for both comparisons). Additionally, there was no difference in Meyers & McKeever (MM) classification (p=0.597). All arthrofibrosis patients received operative treatment (p=0.003), though there was no difference in fixation technique (p=0.734). Intraoperatively, a higher number of screws were used in the arthrofibrosis group (p=0.002) with the placement of hardware more likely to be epiphyseal (p=0.007). Other operative parameters including number of sutures were not different. Post-operatively, arthrofibrosis patients were more likely to have been immobilized in a cast (p<0.001) with no difference observed for weight-bearing status. After multivariate regression, screw number (OR 8.9, CI 1.9-41.7, p=0.005) and immobilization in a cast (OR 7.8, CI 1.0-60.4, p=0.049) remained significant predictors of post-treatment arthrofibrosis.Conclusion:This serves as the largest study of tibial spine fractures to analyze risk factors for the development of post-treatment arthrofibrosis. Our study demonstrates that pre-operative factors were largely similar between groups, but that intra-operative decisions, including the number of screws used for fixation and placement of hardware in relation to the physis, were significant predictors of post-treatment arthrofibrosis. These findings may influence operative decision-making in tibial spine fracture patients. Additionally, post-operative immobilization in a cast should be avoided given the high risk of arthrofibrosis.Table 1.Characteristics of patients with post-operative arthrofibrosis Arthrofibrosis (N=43)No Arthrofibrosis (N=405)P-valueDemographicAge (years)Male: Female ratioBMI11.124:1920.212.0282:12320.40.0650.0640.824InjurySports-related (%)MM classification III/IVConcomitant ACL injury (%)Delay to surgery (days)13 (30.2)20 (64.5)5 (22.7)24.2205 (50.4)134 (59.6)46 (21.6)24.3 0.0120.5970.9020.989OperativeReceived surgery (%)Operative time (min)Treatment type (%)ARIFORIFScrews (%)Number of ScrewsScrew/Suture Placement (%)TransphysealEpiphyseal43 (100.0)142.0 36 (83.7)7 (16.3)22 (51.2)1.8 5 (17.9)23 (82.1)325 (78.5)123.9 269 (82.8)45 (13.8)114 (35.5)1.4 94 (44.5)117 (55.5) 0.0030.209 0.734 0.0460.0020.0050.007Post-operativeImmobilizedCast immobilizationNon-weightbearing41 (97.6)21 (51.2)16 (39.0)11 (34.4)305 (97.8)72 (23.7)208 (68.2)72 (25.4) 0.955<0.0010.277

Weight-bearing status affects in vivo kinematics following mobile-bearing unicompartmental knee arthroplasty.

The effects of weight bearing (WB) on knee kinematics following mobile-bearing unicompartmental knee arthroplasty (UKA) remain unknown. The purpose of this study was to clarify the effects of WB on in vivo kinematics of mobile-bearing UKA during high knee flexion activities. The kinematics of UKA were evaluated under fluoroscopy during squatting (WB) and active-assisted knee flexion (non-weight bearing, NWB). Range of motion, femoral axis rotation relative to the tibia, anteroposterior (AP) translation of the medial and lateral sides, and kinematic pathway were measured. There were no differences in knee flexion range and external rotation of the femur in each flexion angle between the WB conditions. The amount of femoral external rotation between minimum flexion and 60° of flexion during WB was significantly larger than that during NWB, and that between 60° and 130° of flexion during NWB was significantly larger than that during WB. There were no differences in medial AP translation of the femur in each flexion angle between the WB conditions. However, on the lateral side, posterior translation of 52.9 ± 12.7% was observed between minimum flexion and 130° of flexion during WB. During NWB, there was no significant translation between minimum flexion and 60° of flexion; beyond 60° of flexion, posterior translation was 41.6 ± 8.7%. Between 20° and 80° of flexion, the lateral side in WB was located more posteriorly than in NWB (p < 0.05). Mobile-bearing UKA has good anterior stability throughout the range of knee flexion. WB status affects the in vivo kinematics following mobile-bearing UKA. III.

Physiotherapy after tibial plateau fracture fixation: A systematic review of the literature.

Background:Tibial plateau fractures are frequent injuries that orthopaedic surgeons face. It has been reported that they have a significant negative impact on the patients’ lives, decreasing their quality of live, keeping them of work for long periods of time and reducing their activity levels.Aim:Interestingly, there is not enough focus in the literature about the post-operative rehabilitation of these patients. The aim of the present review is to investigate this field of the literature and try to give answers in four main questions: the range of motion exercises post-surgery, the immobilisation, the weight-bearing status and the ongoing rehabilitation.Materials and Methods:A literature search was conducted using the PubMed and the Google Scholar search engines. A total of 39 articles met the criteria to be included in the study.Results:The literature about this subject is scarce and controversial. Early range of motion exercises should be encouraged as soon as possible after the procedure. The immobilisation after plate fixation does not seem to be correlated with any benefits to the patients. The weight-bearing status of the patients was the most controversial in the literature with the early weight-bearing gaining ground at the most recent studies. Tibia plateau fractures can have significant impact on the patients’ lives, so ongoing rehabilitation with focus on quadriceps strengthening and proprioception exercises is recommended.Conclusion:The present literature review illuminates the controversy that exists in the literature about the physiotherapy following tibia plateau fracture fixation. Early range of motion exercises and early weight bearing should be encouraged. Immobilisation does not seem to provide any benefit. Ongoing rehabilitation should be considered with the view of better clinical outcomes.