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Rezapour M, Seymour RB, Sims SH, Karunakar MA, Habet N, Gurcan MN. Employing machine learning to enhance fracture recovery insights through gait analysis. J Orthop Res 2024; 42:1748-1761. [PMID: 38596829 DOI: 10.1002/jor.25837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/16/2024] [Accepted: 02/26/2024] [Indexed: 04/11/2024]
Abstract
This study aimed to explore the potential of gait analysis coupled with supervised machine learning models as a predictive tool for assessing post-injury complications such as infection, malunion, or hardware irritation among individuals with lower extremity fractures. We prospectively identified participants with lower extremity fractures at a tertiary academic center. These participants underwent gait analysis with a chest-mounted inertial measurement unit device. Using customized software, the raw gait data were preprocessed, emphasizing 12 essential gait variables. The data were standardized, and several machine learning models, including XGBoost, logistic regression, support vector machine, LightGBM, and Random Forest, were trained, tested, and evaluated. Special attention was given to class imbalance, addressed using the synthetic minority oversampling technique (SMOTE). Additionally, we introduced a novel methodology to compute the post-injury recovery rate for gait variables, which operates independently of the time difference between the gait analyses of different participants. XGBoost was identified as the optimal model both before and after the application of SMOTE. Before using SMOTE, the model achieved an average test area under the ROC curve (AUC) of 0.90, with a 95% confidence interval (CI) of [0.79, 1.00], and an average test accuracy of 86%, with a 95% CI of [75%, 97%]. Through feature importance analysis, a pivotal role was attributed to the duration between the occurrence of the injury and the initial gait analysis. Data patterns over time revealed early aggressive physiological compensations, followed by stabilization phases, underscoring the importance of prompt gait analysis. χ2 analysis indicated a statistically significant higher readmission rate among participants with underlying medical conditions (p = 0.04). Although the complication rate was also higher in this group, the association did not reach statistical significance (p = 0.06), suggesting a more pronounced impact of medical conditions on readmission rates rather than on complications. This study highlights the transformative potential of integrating advanced machine learning techniques like XGBoost with gait analysis for orthopedic care. The findings underscore a shift toward a data-informed, proactive approach in orthopedics, enhancing patient outcomes through early detection and intervention. The χ2 analysis added crucial insights into the broader clinical implications, advocating for a comprehensive treatment strategy that accounts for the patient's overall health profile. The research paves the way for personalized, predictive medical care in orthopedics, emphasizing the importance of timely and tailored patient assessments.
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Affiliation(s)
- Mostafa Rezapour
- Center for Artificial Intelligence Research, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute and Wake Forest University School of Medicine, Charlotte, North Carolina, USA
| | - Stephen H Sims
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute and Wake Forest University School of Medicine, Charlotte, North Carolina, USA
| | - Madhav A Karunakar
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute and Wake Forest University School of Medicine, Charlotte, North Carolina, USA
| | - Nahir Habet
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute and Wake Forest University School of Medicine, Charlotte, North Carolina, USA
| | - Metin Nafi Gurcan
- Center for Artificial Intelligence Research, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Giordano V, Pires RE, de Faria LPG, Temtemples I, Macagno T, Freitas A, Joeris A, Giannoudis PV. Doctor, When Should I Start Walking? Revisiting Postoperative Rehabilitation and Weight-Bearing Protocols in Operatively Treated Acetabular Fractures: A Systematic Review and Meta-Analysis. J Clin Med 2024; 13:3570. [PMID: 38930099 PMCID: PMC11204460 DOI: 10.3390/jcm13123570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 05/29/2024] [Accepted: 06/07/2024] [Indexed: 06/28/2024] Open
Abstract
Background and Objectives: Management of acetabular fractures is aimed at anatomically reducing and fixing all displaced or unstable fractures, as the accuracy of fracture reduction has been demonstrated to strongly correlate with clinical outcomes. However, there is a noticeable gap in the literature concerning the perioperative and postoperative care of patients with acetabular fractures, which ultimately can be potential risk factors for adverse outcomes and permanent disabilities. This study aimed to systematically review the available literature regarding rehabilitation practices, including weight-bearing protocols, across time points in surgically treated acetabular fracture patients and correlate these practices with functional outcomes. Methods: We systematically reviewed the Medline and PubMed databases and the Cochrane Central Register of Controlled Trials in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The inclusion criteria were studies with adult patients (19+ years), publications from the last 10 years, articles focusing on rehabilitation or mentioning any aspect related to rehabilitation (such as weight-bearing or muscle training), and describing the surgical management of acute, isolated acetabulum fractures. Specific information was collected, including the fracture classification, time to surgery, surgical approach, surgical time, blood loss, fixation strategy, quality of reduction, postoperative rehabilitation protocol, complication rate, type(s) of complication, and outcome measurement(s). The choice(s) of surgical approach, surgical time, blood loss, and fixation strategy were stratified based on the fracture classification. The complication rate and type(s) of complication were calculated for all studies. Fractures were classified based on the Letournel classification. Results: A total of 494 articles were identified from the initial search, of which 22 (1025 patients) were included in the final review. The most common rehabilitation protocol favored isometric quadriceps and abductor strengthening exercises starting on the first postoperative day, with passive hip movement at 1-3 days postoperatively and active hip movement ranging from the first postoperative day to 4 weeks postoperatively. Partial weight-bearing with a walker or a pair of crutches was permitted from 1 to 12 weeks after surgery, and full weight-bearing was allowed depending on the patient's general condition and fracture healing state (generally at the end of 3 months). In only three studies did the patients start bearing weight in the early postoperative period (≤1 week). Meta-regression analysis was not performed due to the discrepancy between studies that reported a weight-bearing protocol ≤1 week and >1 week postoperatively. Conclusions: Our study suggests that an accelerated postoperative rehabilitation protocol, including early permissive weight-bearing, does not appear to increase the risk of loss of reduction or the rate of complications after surgical treatment of acetabular fractures. However, a proper meta-analysis was not possible, and the heterogeneity of the included studies did not allow us to conclude anything about the potential biomechanical and clinical benefits nor the negative effects related to this rehabilitation regimen in terms of functional results. There is an inconsistent use of PROMs for objectively calculating the effect size of the accelerated protocol compared with restricted weight-bearing regimes. We pose the need for higher-level evidence to proof our hypothesis.
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Affiliation(s)
- Vincenzo Giordano
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro 22430-160, Brazil; (L.P.G.d.F.); (I.T.)
| | - Robinson Esteves Pires
- Departamento do Aparelho Locomotor, Escola de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Brazil;
| | - Luiz Paulo Giorgetta de Faria
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro 22430-160, Brazil; (L.P.G.d.F.); (I.T.)
| | - Igor Temtemples
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro 22430-160, Brazil; (L.P.G.d.F.); (I.T.)
| | - Tomas Macagno
- Hospital Sirio Libanés, Buenos Aires C1419, Argentina;
| | - Anderson Freitas
- HOME—Hospital Ortopédico e Medicina Especializada, Brasília 70200-730, Brazil;
| | - Alexander Joeris
- Clinical Science, AO Innovation Translation Center, 8600 Dübendorf, Switzerland;
| | - Peter V. Giannoudis
- Department of Trauma & Orthopaedic Surgery, School of Medicine, University of Leeds, Leeds LS2 9LU, UK;
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Kalmet P, Maduro C, Verstappen C, Meys G, van Horn Y, van Vugt R, Janzing H, van der Veen A, Jaspars C, Sintenie JB, Blokhuis T, Evers S, Seelen H, Brink P, Poeze M. Effectiveness of permissive weight bearing in surgically treated trauma patients with peri- and intra-articular fractures of the lower extremities: a prospective comparative multicenter cohort study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1363-1371. [PMID: 38159217 PMCID: PMC10980603 DOI: 10.1007/s00590-023-03806-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/02/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE The aim of the present study was to investigate the effectiveness of a novel approach involving permissive weight bearing (PWB) in surgically treated trauma patients with peri- and intra-articular fractures of the lower extremities. METHODS Prospective comparative multicenter cohort study in one level 1 trauma center and five level 2 trauma centers. Surgically treated trauma patients with peri- and intra-articular fractures of the lower extremities were included. Permissive weight bearing (PWB) in comparison to restricted weight bearing (RWB) was assessed over a 26-week post-surgery follow-up period. Patients' self-perceived outcome levels regarding activities of daily living (ADL), quality of life (QoL), pain and weight bearing compliance were used. RESULTS This study included 106 trauma patients (N = 53 in both the PWB and RWB groups). Significantly better ADL and QoL were found in the PWB group compared to the RWB group at 2-, 6-, 12- and 26-weeks post-surgery. There were no significant differences in postoperative complication rates between the PWB and RWB groups. CONCLUSION PWB is effective and is associated with a significantly reduced time to full weight bearing, and a significantly better outcome regarding ADL and QoL compared to patients who followed RWB regimen. Moreover, no significant differences in complication rates were found between the PWB and RWB groups. LEVEL OF EVIDENCE Level II. REGISTRATION This study is registered in the Dutch Trial Register (NTR6077). Date of registration: 01-09-2016.
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Affiliation(s)
- Pishtiwan Kalmet
- Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Cherelle Maduro
- Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Coen Verstappen
- Maastricht University Medical Center+, Maastricht, The Netherlands.
| | - Guido Meys
- Adelante Rehabilitation Center, Hoensbroek, The Netherlands
| | | | | | | | | | - Coen Jaspars
- Maxima Medical Center, Veldhoven, The Netherlands
| | | | - Taco Blokhuis
- Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Silvia Evers
- Maastricht University, Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands
- Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
| | - Henk Seelen
- Adelante Rehabilitation Center, Hoensbroek, The Netherlands
- Maastricht University, Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands
| | - Peter Brink
- Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Martijn Poeze
- Maastricht University Medical Center+, Maastricht, The Netherlands
- Nutrim School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, The Netherlands
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Heiman E, Menken LG, Tang A, Vialonga M, Jankowski JM, Liporace FA, Yoon RS. Early versus Standard Weight Bearing Following Operative Treatment of Tibial Plateau Fractures: Do We Really Have to Wait So Long? J Knee Surg 2024; 37:402-408. [PMID: 37586405 DOI: 10.1055/s-0043-1772232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Postoperative management of tibial plateau fractures classically involves a prolonged period between 10 and 12 weeks of nonweight bearing or partial weight bearing. In recent years, there has been some support for earlier weight-bearing protocols although this remains controversial. The goal of this study was to investigate the difference in outcomes between early weight-bearing (EWB) and traditional weight-bearing (TWB) protocols. This investigation is a retrospective review of 92 patients treated with open reduction and internal fixation of tibial plateau fractures at a single institution, from August 2018 to September 2020. Subjects were divided into EWB (< 10 weeks) and traditional nonweight bearing groups (≥ 10 weeks). Key outcome measures collected include injury classification, mechanism of injury, surgical fixation method, bone grafting, time to full weight bearing, radiographic time to union, range-of-motion, all-cause complications, and subsidence at an average follow-up time of 1 year. The EWB group had an earlier average time to weight bearing versus the TWB group (6.5 ± 1.4 vs. 11.8 ± 2.3 weeks, p < 0.0001). There was no difference in the classification of fractures treated between the two groups, with Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association B3 fractures the most common in the EWB group, and C3 fractures the most common in the TWB group. Radiographic time to union was no different between the two groups (93.5 ± 53.7 days for EWB vs. 103.7 ± 77.6 days for TWB, p = 0.49). There was no significant difference in complication rates or subsidence. Following operative treatment of tibial plateau fractures, patients who underwent a weight-bearing protocol earlier than 10 weeks were able to recover faster with similar outcomes and complications compared with patients who started weight bearing after 10 weeks or more. LEVEL OF EVIDENCE: III.
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Affiliation(s)
- Erick Heiman
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center - RWJBarnabas Health, Jersey City, New Jersey
| | - Luke G Menken
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center - RWJBarnabas Health, Jersey City, New Jersey
| | - Alex Tang
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center - RWJBarnabas Health, Jersey City, New Jersey
| | - Mason Vialonga
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center - RWJBarnabas Health, Jersey City, New Jersey
| | - Jaclyn M Jankowski
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center - RWJBarnabas Health, Jersey City, New Jersey
| | - Frank A Liporace
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center - RWJBarnabas Health, Jersey City, New Jersey
| | - Richard S Yoon
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center - RWJBarnabas Health, Jersey City, New Jersey
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Dong W, Lisitano LSJ, Marchand LS, Reider LM, Haller JM. Weight-bearing Guidelines for Common Geriatric Upper and Lower Extremity Fractures. Curr Osteoporos Rep 2023; 21:698-709. [PMID: 37973761 DOI: 10.1007/s11914-023-00834-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review paper is to summarize current weight-bearing guidelines for common geriatric fractures, around weight-bearing joints, of the upper and lower extremities. RECENT FINDINGS There is an increasing amount of literature investigating the safety and efficacy of early weight-bearing in geriatric fractures, particularly of the lower extremity. Many recent studies, although limited, suggest that early weight-bearing may be safe for geriatric distal femur and ankle fractures. Given the limited data pertaining to early weight-bearing in geriatric fractures, it is difficult to establish concrete weight-bearing guidelines in this population. However, in the literature available, early weight-bearing appears to be safe and effective across most injuries. The degree and time to weight-bearing vary significantly based on fracture type and treatment method. Future studies investigating postoperative weight-bearing protocols should focus on the growing geriatric population and identify methods to address specific barriers to early weight-bearing in these patients such as cognitive impairment, dependence on caregivers, and variations in post-acute disposition.
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Affiliation(s)
- Willie Dong
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Leonard S J Lisitano
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Lucas S Marchand
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Lisa M Reider
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Justin M Haller
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
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Junior MDSL, Ciardullo MB, Neto OC, Herrera YEG, Ochoa PGG, Silva JDS, Kojima KE. Protected immediate weight-bearing is safe after fixation of ankle fractures with syndesmosis injury fixed with position screw. A retrospective case-series study. Injury 2023; 54 Suppl 6:110745. [PMID: 38143122 DOI: 10.1016/j.injury.2023.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/15/2023] [Accepted: 04/14/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND About 10% of ankle fractures are located above the syndesmosis, which causes injury to the ligament structure of the syndesmosis. There is no consensus regarding when to allow weight-bearing on the operated limb of patients who suffered ankle fractures requiring intraoperative fixation. OBJECTIVE The aim of this study is the evaluation of radiographic parameters of syndesmosis reduction and fixation in patients with ankle fracture who underwent immediate protected weight-bearing (use of walking-boot and crutches). PATIENT AND METHODS Retrospective case series from January 2015 to December 2020. Evaluation of the tibiofibular clear space, tibiofibular overlap, and medial clear space in the preoperative x-ray, immediate postoperative, 3-, 6- and 12-month after syndesmosis fixation and rehabilitation with protected immediate weight-bearing with crutches and walking-boot. RESULTS Out of 137 ankle fractures 39 were included. There was no significant difference in the tibiofibular clear space between the immediate x-ray and after 12 months (4.5 mm ± 1.1 vs. 4.6 mm ± 1.8; p > 0.999). Tibiofibular overlap hasn't shown significant difference between immediate and 12-month x-ray (6.2 mm ± 2.6 vs. 6.6 mm ± 2.6; p > 0.999). Medial clear space also has shown no worsening from immediate to 12-month x-ray (3.1 mm ± 0.9 vs. 2.8 mm ± 0.9; p > 0.999). There were no fixation failure nor postoperative infection. CONCLUSION Immediate weight-bearing for patients with ankle fractures with syndesmosis injury and treated with intraoperative fixation with positioning screw proved to be safe with good maintenance of the reduction, no failures of the synthesis material observed and no reports of postoperative infection in the period. LEVEL 3 EVIDENCE: therapeutic retrospective case-series.
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Affiliation(s)
- Milton da Silva Linhares Junior
- Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
| | - Marcos Broggi Ciardullo
- Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
| | - Orlando Colavolpe Neto
- Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
| | - Yasmín Estefanía González Herrera
- Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
| | - Pablo Gabriel Garcia Ochoa
- Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
| | - Jorge Dos Santos Silva
- Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
| | - Kodi Edson Kojima
- Trauma Service, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
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Kojima KE, Munari BM, Kubota BS, Zanesco L, Proença DS, Leonhardt MDC, Silva JDS. RADIOGRAPHIC EVALUATION OF IMMEDIATE LOADING SAFETY AFTER SURGICAL REDUCTION IN ACETABULAR FRACTURES: A COMPARATIVE-RETROSPECTIVE STUDY. ACTA ORTOPEDICA BRASILEIRA 2022; 30:e256907. [PMID: 36506862 PMCID: PMC9721436 DOI: 10.1590/1413-785220223002e256907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 07/21/2021] [Indexed: 12/05/2022]
Abstract
Objective Radiographically evaluate the quality of reduction over six weeks of follow-up in patients with surgically treated deviated acetabular fractures who underwent rehabilitation with immediate loading as tolerated and compare this with the results of the unloaded protocol. Methods We retrospectively evaluated the records of 137 patients with deviated acetabular fractures treated with open reduction and internal fixation. Sixty-six (48.2%) patients underwent postoperative rehabilitation with immediate loading as tolerated, while 71 (51.8%) patients completed rehabilitation using a no-load protocol. The quality of the reduction was assessed radiographically by measuring the fracturing step and gap on radiographs taken immediately after surgery and three and six weeks after surgery. Results Comparing the joint step, group 1 had an average of 0.44 ± 1.4 mm, 0.47 ± 1.5 mm, and 0.51 ± 1.6 mm immediately, three and six weeks after surgery, respectively. Group 2 had a mean step of 0.24 ± 0.8 mm, 0.27 ± 0.9 mm, and 0.37 ± 1.2 mm immediately, three, and six weeks after surgery. No statistically significant differences were observed between the groups. With a joint gap, group 1 had a mean of 1.89 ± 1.7 mm, 2.12 ± 1.8 mm, and 2.36 ± 2.1 mm; and group 2 had a mean of 2.16 ± 2.4 mm, 2.47 ± 2.6 mm, and 2.67 ± 2.8 mm in the immediate postoperative period, three, and six weeks, respectively. There was also no statistical difference between groups in these measurements. Conclusion Immediate loading after surgical treatment of deviated acetabular fracture had no negative impact on radiographic reduction parameters and had similar results to the protocol without weight bearing. Level of evidence III; Therapeutic Retrospective Cohort Study .
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Affiliation(s)
- Kodi Edson Kojima
- Universidade de São Paulo, Faculty of Medicine, Hospital das Clínicas, Institute of Orthopedics and Traumatology, Trauma Group, HC-DOT/FMUSP, São Paulo, SP, Brazil
| | - Bruno Mendes Munari
- Universidade de São Paulo, Faculty of Medicine, Hospital das Clínicas, Institute of Orthopedics and Traumatology, Trauma Group, HC-DOT/FMUSP, São Paulo, SP, Brazil
| | - Bruno Seiki Kubota
- Universidade de São Paulo, Faculty of Medicine, Hospital das Clínicas, Institute of Orthopedics and Traumatology, Trauma Group, HC-DOT/FMUSP, São Paulo, SP, Brazil
| | - Leonardo Zanesco
- Universidade de São Paulo, Faculty of Medicine, Hospital das Clínicas, Institute of Orthopedics and Traumatology, Trauma Group, HC-DOT/FMUSP, São Paulo, SP, Brazil
| | - Daniel Sonnewend Proença
- Universidade de São Paulo, Faculty of Medicine, Hospital das Clínicas, Institute of Orthopedics and Traumatology, Trauma Group, HC-DOT/FMUSP, São Paulo, SP, Brazil
| | - Marcos de Camargo Leonhardt
- Universidade de São Paulo, Faculty of Medicine, Hospital das Clínicas, Institute of Orthopedics and Traumatology, Trauma Group, HC-DOT/FMUSP, São Paulo, SP, Brazil
| | - Jorge dos Santos Silva
- Universidade de São Paulo, Faculty of Medicine, Hospital das Clínicas, Institute of Orthopedics and Traumatology, Trauma Group, HC-DOT/FMUSP, São Paulo, SP, Brazil
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Hammarstedt JE, Redshaw JT, Schimoler PJ, Westrick ER, Andreini D, Kharlamov A, Miller MC. Biomechanical analysis of stability of joint depression calcaneal fractures: Fixation with locking compression plate alone compared with addition of supplemental oblique screw. J Clin Orthop Trauma 2022; 33:101998. [PMID: 36089992 PMCID: PMC9460535 DOI: 10.1016/j.jcot.2022.101998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 08/03/2022] [Accepted: 08/22/2022] [Indexed: 11/20/2022] Open
Abstract
Purpose The standard treatment of calcaneus fractures is a lateral plate and screw construct. Patients at our institution have been treated with a lateral locking plate combined with one retrograde screw inserted in the oblique plane to allow immediate weight bearing. The purpose of this study was to determine whether addition of a oblique screw to a lateral plate construct increases stability. Methods A Sanders 2B fracture (AO/OTA 83-C2) was created in 8 pairs (16 total specimens) of cadaveric feet. All were repaired using a lateral locking plate/screws construct. One specimen in each pair was chosen randomly to receive an additional oblique screw. The specimens were tested with cyclic load of up to 800 N. Movement at the fracture sites and subsidence of the talus were tracked with a three-dimensional video analysis system. Results Talar subsidence was not significantly affected by the presence of the additional oblique screw (p = 0.22). The sustentaculum fragment in the case of the screw repair moved 0.39 mm while the same fragment without the additional screw repair displaced 0.12 mm (p < 0.01). Two repairs with and one repair without the additional screw failed during longer-term cyclic loading. Conclusion The two repair types were not statistically different in regards to talar subsidence. While statistical significance resulted in the comparison of sustentaculum fragment movement, the amount of movement did not reach a level of clinical relevance. This study demonstrated immediate stability and durability of the additional screw construct with high volume weight bearing loads.
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Affiliation(s)
- Jon E. Hammarstedt
- Allegheny Health Network, Department of Orthopaedic Surgery, Pittsburgh, PA, 15212, USA
| | - James T. Redshaw
- Allegheny Health Network, Department of Orthopaedic Surgery, Pittsburgh, PA, 15212, USA
| | - Patrick J. Schimoler
- Allegheny Health Network, Department of Orthopaedic Surgery, Pittsburgh, PA, 15212, USA
- University of Pittsburgh, Department of Mechanical Engineering and Materials Science, Pittsburgh, PA, 15213, USA
| | - Edward R. Westrick
- Allegheny Health Network, Department of Orthopaedic Surgery, Pittsburgh, PA, 15212, USA
| | - Derek Andreini
- Allegheny Health Network, Department of Orthopaedic Surgery, Pittsburgh, PA, 15212, USA
| | - Alexander Kharlamov
- Allegheny Health Network, Department of Orthopaedic Surgery, Pittsburgh, PA, 15212, USA
| | - Mark Carl Miller
- Allegheny Health Network, Department of Orthopaedic Surgery, Pittsburgh, PA, 15212, USA
- University of Pittsburgh, Department of Mechanical Engineering and Materials Science, Pittsburgh, PA, 15213, USA
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Canton G, Sborgia A, Dussi M, Rasio N, Murena L. Early weight bearing in tibial plateau fractures treated with ORIF: a systematic review of literature. J Orthop Surg Res 2022; 17:261. [PMID: 35549974 PMCID: PMC9097122 DOI: 10.1186/s13018-022-03156-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To review the current clinical evidence on advantages and risks of early weight bearing (EWB) after internal fixation for tibial plateau fracture. METHODS Data source: PubMed and Google Scholar from inception of database to 20 August 2021, using PRISMA guidelines. The included studies were randomized controlled trials, prospective and retrospective observational studies, case reports. Data extraction was performed independently by 2 reviewers. Collected data were compared to verify agreement. Statistical analysis was not performed in this study. RESULTS The literature search produced 174 papers from PubMed and 186 from Google Scholar, with a total amount of 360 papers. The two reviewers excluded 301 papers by title or duplicates. Of the 59 remaining, 33 were excluded after reading the abstract, and 17 by reading the full text. Thus, 9 papers were finally included in the review. CONCLUSIONS EWB can be considered safe and effective in selected cases after internal fixation for tibial plateau fractures. Level of evidence Therapeutic Level III.
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Affiliation(s)
- Gianluca Canton
- Orthopaedics and Traumatology Unit, Department of Medical, Surgical and Life Sciences, Cattinara Hospital, Trieste University, Strada di Fiume 447, 34149, Trieste, Italy
| | - Andrea Sborgia
- Orthopaedics and Traumatology Unit, Department of Medical, Surgical and Life Sciences, Cattinara Hospital, Trieste University, Strada di Fiume 447, 34149, Trieste, Italy.
| | - Micol Dussi
- Orthopaedics and Traumatology Unit, Department of Medical, Surgical and Life Sciences, Cattinara Hospital, Trieste University, Strada di Fiume 447, 34149, Trieste, Italy
| | - Nicholas Rasio
- Orthopaedics and Traumatology Unit, Department of Medical, Surgical and Life Sciences, Cattinara Hospital, Trieste University, Strada di Fiume 447, 34149, Trieste, Italy
| | - Luigi Murena
- Orthopaedics and Traumatology Unit, Department of Medical, Surgical and Life Sciences, Cattinara Hospital, Trieste University, Strada di Fiume 447, 34149, Trieste, Italy
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10
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Kalmet P, Andriessen MT, Maduro CV, van den Boom N, Moens-Oyen C, Hiligsmann M, Janzing H, van der Veen A, Jaspars C, Sintenie JB, Seelen H, Brink P, Poeze M, Evers S. The economic burden of the postoperative management in surgically treated trauma patients with peri- and/or intra-articular fractures of the lower extremities: A prospective multicenter cohort study. Injury 2022; 53:713-718. [PMID: 34809922 DOI: 10.1016/j.injury.2021.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 10/29/2021] [Accepted: 11/07/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To estimate the economic burden expressed in costs and quality of life of the post-surgical treatment of peri‑ and/or intra-articular fractures in the lower extremity from a societal perspective. DESIGN This is a quantitative study as it aims to find averages and generalize results to wider populations. The design is a cost-of-illness and quality of life study focusing on costs (in euros), Activities of Daily Living (ADL) and Quality of Life (Qol) in patients with peri‑ and/or intra-articular fractures of the lower extremities. SETTING Surgically treated trauma patients with peri‑ and/or intra-articular fractures of the lower extremities during 26 weeks follow-up. Patients were included from 4 hospitals in the Netherlands. MAIN OUTCOME MEASURES Costs, ADL and Quality Adjusted Life Years (QALY). METHODS Cost of illness was estimated through a bottom-up method. The Dutch Eq-5D-5 L questionnaire was used to calculate utilities while Lower Extremity Functional Scale (LEFS) scores were used as a measure of ADL. Non-parametric bootstrapping was used to test for statistical differences in costs. Subgroup analyses were performed to determine the influence of work status and further sensitivity analyses were performed to test the robustness of the results. RESULTS Total average societal costs were € 9836.96 over six months. Unexpectedly, total societal and healthcare costs were lower for patients with a paid job relative to patients without. Sensitivity analyses showed that our choice of a societal perspective and the EuroQol as our primary utility measurement tool had a significant effect on the outcomes. The ADL at baseline was respectively; 10.4 and at 26 weeks post-surgery treatment 49.5. The QoL was at baseline respectively; 0.3 and at 26 weeks post-surgery treatment 0.7. These findings are indicative of a significantly improved ADL and QoL (p ≤ 0.05) over time. CONCLUSIONS This study reveal a substantial economic burden in monetary terms and effect on QoL of patients with peri‑ and/or intra-articular fractures of the lower extremities during 26 weeks follow-up. REGISTRATION This study was registered in the Dutch Trial Register (NTR6077). Date of registration: 01-09-2016.
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Affiliation(s)
- Phs Kalmet
- Maastricht University Medical Center+, Maastricht, the Netherlands
| | | | - C V Maduro
- Maastricht University Medical Center+, Maastricht, the Netherlands; Maastricht University, Maastricht, the Netherlands.
| | - N van den Boom
- Maastricht University Medical Center+, Maastricht, the Netherlands
| | | | - M Hiligsmann
- Maastricht University, Care and Public Health Research Institute (CAPHRI), Maastricht, the Netherlands
| | - H Janzing
- Viecuri Medical Center, Venlo, the Netherlands
| | | | - C Jaspars
- Maxima Medical Center, Veldhoven, the Netherlands
| | | | - Ham Seelen
- Maastricht University, Care and Public Health Research Institute (CAPHRI), Maastricht, the Netherlands; Adelante Rehabilitation Center, Hoensbroek, the Netherlands
| | - Prg Brink
- Maastricht University Medical Center+, Maastricht, the Netherlands
| | - M Poeze
- Maastricht University Medical Center+, Maastricht, the Netherlands; Nutrim School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Smaa Evers
- Maastricht University, Care and Public Health Research Institute (CAPHRI), Maastricht, the Netherlands; Trimbos Institute, Netherlands Institute of Mental Health and Addiction, the Netherlands
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11
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Raza M, Walters S, Richardson C, Bretherton C, Longhurst K, Trompeter A. Weight-bearing in Trauma Surgery (WiTS) Study: A national survey of UK Trauma & Orthopaedic multidisciplinary health professionals. Injury 2022; 53:427-433. [PMID: 34937671 DOI: 10.1016/j.injury.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/06/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Weight-bearing (WB) status following a fracture or surgical fixation is an important determinant of the mechanical environment for healing. In order for healthcare professionals to communicate and understand the extent of bearing weight through a limb, clear terminology must be used. There is widespread variation in the usage and definitions of WB terminology in the literature and clinical practice. This study sought to define the understanding and extent of variation across the United Kingdom. METHODS A nationwide online survey of UK-based Trauma & Orthopaedic (T&O) multidisciplinary healthcare professionals was conducted. Participants answered seven questions assessing their usage and understanding of various WB terminology. RESULTS A total of 707 responses were received: 48% by doctors, 32% by physiotherapists, 13% by occupational therapists and 7% from other healthcare professionals. In terms of understanding of WB terminology with respect to percentage body weight (BW), 89% of respondents interpret 'full WB' as 100% BW, 97% interpret 'non WB' as 0% BW, 80% interpret 'partial WB' as 50% BW, and 89% interpret 'touch/toe-touch WB' as 10% or 20% BW. There were statistically significant differences between the responses of doctors and therapists for these four terms, with doctors tending to give higher %BW values. 'Protected WB' and 'WB as tolerated' had less consensus and more variability in responses. The majority (68%) of respondents do not usually quantify terminology such as 'partial WB' with a value, and 94% agreed that standardisation of WB terminology would improve communication amongst professionals. CONCLUSION This study provides evidence of the substantial variation in the understanding of WB terminology amongst healthcare professionals, which likely results in ambiguous rehabilitation advice. Existing literature has shown that patients struggle to comply with terms such as 'partial weight-bearing'. We recommend consensus within the T&O multidisciplinary community to standardise and define common weight-bearing terminology.
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Affiliation(s)
- M Raza
- Department of Trauma & Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, UK.
| | - S Walters
- Department of Trauma & Orthopaedics, Epsom & St Helier University Hospitals NHS Trust, London, UK
| | - C Richardson
- Department of Trauma & Orthopaedics, Epsom & St Helier University Hospitals NHS Trust, London, UK
| | - C Bretherton
- Department of Trauma & Orthopaedics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - K Longhurst
- Department of Physiotherapy, St George's University Hospitals NHS Foundation Trust, London, UK
| | - A Trompeter
- Department of Trauma & Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, UK
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12
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Working ZM, Peterson D, Lawson M, O’Hara K, Coghlan R, Provencher MT, Friess DM, Johnstone B, Miclau T, Bahney CS. Collagen X Longitudinal Fracture Biomarker Suggests Staged Fixation in Tibial Plateau Fractures Delays Rate of Endochondral Repair. J Orthop Trauma 2022; 36:S32-S39. [PMID: 35061649 PMCID: PMC10308601 DOI: 10.1097/bot.0000000000002307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To use a novel, validated bioassay to monitor serum concentrations of a breakdown product of collagen X in a prospective longitudinal study of patients sustaining isolated tibial plateau fractures. Collagen X is the hallmark extracellular matrix protein present during conversion of soft, cartilaginous callus to bone during endochondral repair. Previous preclinical and clinical studies demonstrated a distinct peak in collagen X biomarker (CXM) bioassay levels after long bone fractures. SETTING Level 1 academic trauma facility. PATIENTS/PARTICIPANTS Thirty-six patients; isolated tibial plateau fractures. INTERVENTION (3) Closed treatment, ex-fix (temporizing/definitive), and open reduction internal fixation. MAIN OUTCOME MEASUREMENTS Collagen X serum biomarker levels (CXM bioassay). RESULTS Twenty-two men and 14 women (average age: 46.3 y; 22.6-73.4, SD 13.3) enrolled (16 unicondylar and 20 bicondylar fractures). Twenty-five patients (72.2%) were treated operatively, including 12 (33.3%) provisionally or definitively treated by ex-fix. No difference was found in peak CXM values between sexes or age. Patients demonstrated peak expression near 1000 pg/mL (average: male-986.5 pg/mL, SD 369; female-953.2 pg/mL, SD 576). There was no difference in peak CXM by treatment protocol, external fixator use, or fracture severity (Schatzker). Patients treated with external fixation (P = 0.05) or staged open reduction internal fixation (P = 0.046) critically demonstrated delayed peaks. CONCLUSIONS Pilot analysis demonstrates a strong CXM peak after fractures commensurate with previous preclinical and clinical studies, which was delayed with staged fixation. This may represent the consequence of delayed construct loading. Further validation requires larger cohorts and long-term follow-up. Collagen X may provide an opportunity to support prospective interventional studies testing novel orthobiologics or fixation techniques. LEVEL OF EVIDENCE Level II, prospective clinical observational study.
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Affiliation(s)
- Zachary M. Working
- Department of Orthopaedics & Rehabilitation, Oregon Health and Science University, Portland, OR
| | - Danielle Peterson
- Department of Orthopaedics & Rehabilitation, Oregon Health and Science University, Portland, OR
| | - Michelle Lawson
- Department of Orthopaedics & Rehabilitation, Oregon Health and Science University, Portland, OR
| | | | | | | | - Darin M. Friess
- Department of Orthopaedics & Rehabilitation, Oregon Health and Science University, Portland, OR
| | - Brian Johnstone
- Department of Orthopaedics & Rehabilitation, Oregon Health and Science University, Portland, OR
- Portland Shriners Hospital, Portland, OR
| | - Theodore Miclau
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California at San Francisco, San Francisco, CA
| | - Chelsea S. Bahney
- Steadman Philippon Research Institute, Vail, CO
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California at San Francisco, San Francisco, CA
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13
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Stinner DJ, Rivera JC, Smith CS, Weiss DB, Hymes RA, Matuszewski PE, Gary JL, Morshed S, Schmidt AH, Wilken JM, Archer KR, Bailey L, Kleihege J, McLaughlin KH, Thompson RE, Chung S, Remenapp C, MacKenzie EJ, Reider L. Early Advanced Weight-Bearing After Periarticular Fractures: A Randomized Trial Comparing Antigravity Treadmill Therapy Versus Standard of Care. J Orthop Trauma 2022; 36:S8-S13. [PMID: 34924513 DOI: 10.1097/bot.0000000000002285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/07/2021] [Indexed: 02/02/2023]
Abstract
SUMMARY In current clinical practice, weight-bearing is typically restricted for up to 12 weeks after definitive fixation of lower extremity periarticular fractures. However, muscle atrophy resulting from restricting weight-bearing has a deleterious effect on bone healing and overall limb function. Antigravity treadmill therapy may improve recovery by allowing patients to safely load the limb during therapy, thereby reducing the negative consequences of prolonged non-weight-bearing while avoiding complications associated with premature return to full weight-bearing. This article describes a multicenter randomized controlled trial comparing outcomes after a 10-week antigravity treadmill therapy program versus standard of care in adult patients with periarticular fractures of the knee and distal tibia. The primary hypothesis is that, compared with patients receiving standard of care, patients receiving antigravity treadmill therapy will report better function 6 months after definitive treatment.
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Affiliation(s)
- Daniel J Stinner
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Jessica C Rivera
- U.S. Army Institute for Surgical Research, Brooke Army Medical Center, San Antonio, TX. Dr. Rivera is now with the Department of Orthopaedic Surgery, Louisiana State University Medical Center, New Orleans, LA
| | - Christopher S Smith
- Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, VA
| | - David B Weiss
- Department of Orthopaedic Surgery, University of Virginia Medical Center, Charlottesville, VA
| | - Robert A Hymes
- Department of Orthopaedic Surgery, Inova Fairfax Medical Campus, Falls Church, VA
| | - Paul E Matuszewski
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY
| | - Joshua L Gary
- Department of Orthopaedic Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX (now at the Department of Orthopaedic Surgery, at the Keck School of Medicine, University of Southern California, Los Angeles, CA)
| | - Saam Morshed
- Department of Orthopaedic Surgery, University of California, San Francisco, CA
| | - Andrew H Schmidt
- Department of Orthopaedic Surgery, Hennepin Healthcare, Minneapolis, MN
| | - Jason M Wilken
- Department of Physical Therapy and Rehabilitation Sciences, University of Iowa, Iowa City, IA
| | - Kristin R Archer
- Department of Orthopaedic Surgery, Center for Musculoskeletal Research and Department of Physical Medicine and Rehabilitation, Osher Center for Integrative Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Lane Bailey
- Memorial Hermann IRONMAN Sports Medicine Institute, Houston, TX
| | | | - Kevin H McLaughlin
- Department of Physical Medicine and Rehabilitation, John Hopkins University, Baltimore, MD
| | - Richard E Thompson
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; and
| | - Suna Chung
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Craig Remenapp
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Ellen J MacKenzie
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Lisa Reider
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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14
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Li Z, Maimaitiming D, Sun L, Wang H, Xiong W. Rehabilitative management of pelvic fractures needs to be further optimized. Eur J Transl Myol 2021; 31. [PMID: 34856742 PMCID: PMC8758956 DOI: 10.4081/ejtm.2021.10246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 11/18/2021] [Indexed: 02/08/2023] Open
Abstract
We read with interest the review by Piccione et al. into the rehabilitative management of patients with pelvic fracture (PF). This review adds to our knowledge about the significance and indispensability of early multidisciplinary intervention in PF. From our perspective, however, potential bias might be caused by several unanswered questions. The uncertain methodological process and the unclear definition could misguide the rehabilitation strategies while still in dispute. Therefore, further high-quality studies should be conducted to optimize the multidisciplinary rehabilitation of patients with PF.
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Affiliation(s)
- Zehua Li
- Department of Burn and Plastic Surgery, West China Hospital of Sichuan University, Chengdu.
| | | | - Leqi Sun
- Queen Square Institute of Neurology, University College London (UCL), London.
| | - Haoran Wang
- Department of Burn and Plastic Surgery, West China Hospital of Sichuan University, Chengdu.
| | - Weixi Xiong
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China; Institute of Brain Science and Brain-inspired technology of West China Hospital, Sichuan University, Chengdu.
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15
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Falls from height: Ambulation following spinal cord injury and lower extremity polytrauma. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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16
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Palke L, Schneider S, Karich B, Mende M, Josten C, Böhme J, Henkelmann R. Anti-gravity treadmill rehabilitation improves gait and muscle atrophy in patients with surgically treated ankle and tibial plateau fractures after one year: A randomised clinical trial. Clin Rehabil 2021; 36:87-98. [PMID: 34355605 DOI: 10.1177/02692155211037148] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare the one-year postoperative outcomes of anti-gravity treadmill rehabilitation with those of standard rehabilitation in patients with ankle or tibial plateau fractures. DESIGN An open-label prospective randomised study. SETTING Three trauma centres. SUBJECTS Patients were randomised into the intervention (anti-gravity treadmill) or control (standard protocol) rehabilitation group. MAIN MEASURES The primary endpoint was changes in the Foot and Ankle Outcome Score for ankle fractures and Knee Injury and Osteoarthritis Outcome Score for tibial plateau fractures from baseline to 12 months after operation. Secondary endpoints were the subscores of these scores, muscle atrophy (leg circumference at 20 cm above and 10 cm below the knee joint) and the Dynamic Gait Index. RESULTS Initially, 73 patients (37 vs 36) underwent randomisation. After 12 months, 29 patients in the intervention group and 24 patients in the control group could be analysed. No significant difference was noted in the Foot and Ankle Outcome Score (80.8 ± 18.4 and 78.4 ± 21.1) and Knee Injury and Osteoarthritis Outcome Score (84.8 ± 15.2 and 81.7 ± 17.0). The change in the Dynamic Gait Index from 12 weeks to 12 months differed significantly between the groups (P = 0.04). Patients with tibial plateau fractures had a 3 cm wider thigh circumference in the intervention group than those in the control group (95% confidence interval: -0.2 to 6.3 cm, P = 0.08). CONCLUSION One year after surgery, patients who had undergone anti-gravity treadmill rehabilitation showed better gait than patients in the control group, and those with tibial plateau fractures had less muscle atrophy.
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Affiliation(s)
- Lisa Palke
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
| | - Sebastian Schneider
- Hospital St. Georg GmbH, Clinic of Trauma, Orthopaedic and Septic Surgery, Leipzig, Germany; Ambulantes Reha Centrum Leipzig GmbH, Leipzig, Germany
| | - Bernhard Karich
- Department of Trauma and Physical Medicine, Heinrich-Braun-Klinikum GmbH, Zwickau, Germany
| | - Meinhard Mende
- Centre for Clinical Trials and Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
| | - Christoph Josten
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
| | - Jörg Böhme
- Hospital St. Georg GmbH, Clinic of Trauma, Orthopaedic and Septic Surgery, Leipzig, Germany; Ambulantes Reha Centrum Leipzig GmbH, Leipzig, Germany
| | - Ralf Henkelmann
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
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17
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Myers DM, Pulido SH, Forsting S, Umbel B, Taylor BC. Effect of Early Weight Bearing on Outcomes After Open Reduction and Internal Fixation of Trimalleolar Ankle Fractures. Orthopedics 2021; 44:160-165. [PMID: 33416898 DOI: 10.3928/01477447-20210104-04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Current practice allows early weight bearing of unstable ankle fractures after fixation. This study offers a unique comparison of early weight bearing (EWB) vs late weight bearing (LWB) in operatively stabilized trimalleolar ankle fractures. The goal of this study was to evaluate union rates, clinical outcomes, and complications for patients who were managed with EWB vs LWB. The authors performed a retrospective review of 185 patients who underwent surgical stabilization for trimalleolar ankle fracture. Fixation of the posterior malleolus and weight bearing status were determined by surgeon preference. For this study, EWB was defined as 3 weeks or less and LWB was defined as greater than 3 weeks. Patients were evaluated for fracture union and implant failure. Complications and clinical outcomes included ambulatory status, infection rate, and return to surgery. The EWB group included 47 (25.4%) patients, and the LWB group included 138 (74.6%) patients. Of the 7 nonunions, 1 (14.3%) occurred in the EWB group and 6 (85.7%) in the LWB group. A total of 72 (38.9%) posterior malleolar fractures were operatively stabilized, and stabilization did not affect union rates. Syndesmotic fixation was required for 12.5% of patients, despite posterior malleolar stabilization. Syndesmotic fixation increased the union rate 2.5 times. Deep infection and open fracture decreased union. No difference was seen between groups in implant failure, union rate, infection, or return to the operating room. No deleterious effect of EWB in operatively treated trimalleolar ankle fractures was found for union, implant failure, infection, or reoperation. Syndesmotic fixation may offer an advantage over posterior malleolar fixation, with improved union rates. [Orthopedics. 2021;44(3):160-165.].
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18
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Bradman K, Stannage K, O'Brien S, Green S, Bear N, Borland M. Randomised controlled trial comparing immobilisation in above-knee plaster of Paris to controlled ankle motion boots in undisplaced paediatric spiral tibial fractures. Emerg Med J 2021; 38:600-606. [PMID: 34158387 DOI: 10.1136/emermed-2020-210299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 06/13/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Management of common childhood spiral tibial fractures, known as toddler's fractures, has not significantly changed in recent times despite the availability of immobilisation devices known as controlled ankle motion (CAM) boots. We compared standard therapy with these devices on quality-of-life measures. METHODS A prospective randomised controlled trial, comparing immobilisation with an above-knee plaster of Paris cast (AK-POP) with a CAM boot in children aged 1-5 years with proven or suspected toddler's fractures presenting to a tertiary paediatric ED in Perth, Western Australia, between March 2018 and February 2020. The primary outcome measure was ease of personal care, as assessed by a Care and Comfort Questionnaire (eight questions scored from 0, very easy, to 8, impossible) completed by the caregiver and assessed during three treatment time-points and preintervention and postintervention. Secondary outcome measures included weight-bearing status as well as complications of fracture healing and number of pressure injuries. RESULTS 87 patients were randomised (44 CAM boot, median age 2 (IQR 1.5-2.3), 71% male; 43 AK-POP, median age 2 (IQR 1.7-2.8), 80% male), a significant difference in the care and comfort score was demonstrated at all treatment time-points; with the AK-POP group reporting greater personal care needs on assessment on day 2, day 7-10 and 4-week review (all p≤0.001). Weight-bearing status was significantly different at day 7-10 (77.5% CAM vs 53.8% AK-POP, p=0.027). There was no difference in fracture healing or pressure areas between the two treatment groups. CONCLUSIONS Immobilisation of toddler's fractures in a CAM boot allows faster return to activities of daily living and weight-bearing without any effect on fracture healing. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (ACTRN12618001311246).
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Affiliation(s)
- Kate Bradman
- Emergency, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Katherine Stannage
- Department of Orthopaedic Surgery, Perth Children's Hospital, Perth, Western Australia
| | - Sharon O'Brien
- Emergency, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Simon Green
- Emergency, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Natasha Bear
- Institute of Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Meredith Borland
- Emergency, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Paediatric and Emergency Medicine, The University of Western Australia Faculty of Medicine Dentistry and Health Sciences, Perth, Western Australia, Australia
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19
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Immediate Weight-Bearing and Range of Motion After Internal Fixation of Selected Malleolar Fractures: A Retrospective Controlled Study. J Orthop Trauma 2021; 35:308-314. [PMID: 33177430 DOI: 10.1097/bot.0000000000002003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/02/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We studied the safety of immediate weight-bearing as tolerated (IWBAT) and immediate range of motion (IROM) after open reduction internal fixation (ORIF) of selected malleolar ankle fractures (defined as involving bony or ligamentous disruption of 2 or more of the malleoli or syndesmosis without articular comminution) and attempted to identify risk factors for complications. DESIGN Retrospective case-control study. SETTING Level 1 Urban Trauma Center and multiple community hospitals, orthopedic specialty hospitals, and outpatient surgicenters within one metropolitan area. PATIENTS/PARTICIPANTS Of 268 patients at our level 1 trauma center who underwent primary ORIF of a selected malleolar fracture from 2013 to 2018, we identified 133 (49.6%) who were selected for IWBAT and IROM. We used propensity score matching to identify 172 controls who were non-weight-bearing (NWB) and no range of motion for 6 weeks postoperatively. The groups did not differ significantly in age, body mass index, Charleston Comorbidity Index, smoking status, diabetes status, malleoli involved, percentages undergoing medial malleolus (60.9% IWBAT vs. 51.7% NWB), posterior malleolus (24.1% IWBAT, 26.7% NWB), or syndesmosis fixation (41.4% IWBAT, 42.4% NWB, P = 0.85). INTERVENTION IWBAT and IROM after ankle ORIF versus NWB for 6 weeks. MAIN OUTCOME MEASUREMENTS Postoperative complications, including delayed wound healing, superficial or deep infection, and loss of reduction. RESULTS There was no significant difference in total complications (P = 0.41), nonoperative complications (P = 0.53), or operative complications, including a loss of reduction (P = 0.89). We did not identify any factors associated with an increased complication risk, including posterior malleolus or syndesmosis fixation, diabetes, age, or preinjury-assisted ambulation. CONCLUSIONS We failed to demonstrate a difference in complications in general and loss of reduction in particular when allowing immediate weight-bearing/ROM in selected cases of operatively treated malleolar fractures, suggesting this may be safe. Future prospective randomized studies are necessary to determine if immediate weight-bearing/ROM is safe and whether it offers any benefits to patients with operatively treated malleolar fractures. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Abstract
Ankle fractures remain the third most common musculoskeletal injury in the elderly population. The presence of osteoporosis, significant multiple comorbidities and limited functional independence makes treatment of such injuries challenging. Early studies highlighted high rates of post-operative complications and poor outcomes after surgical intervention. With advances in surgical techniques and a greater understanding of multi-disciplinary team (MDT)-driven peri-operative care and rehabilitation, evidence now appears to suggest improved outcomes for operative management. Approaches must be adapted according to co-morbidities, baseline function and patient wishes. This review article aims to discuss contemporary treatment strategies and the complex challenges associated with the management of the elderly ankle fracture.
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21
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Affiliation(s)
- Alex Trompeter
- St George’s University Hospital NHS Foundation Trust, St George’s University of London, London, UK
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22
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Patient-reported quality of life and pain after permissive weight bearing in surgically treated trauma patients with tibial plateau fractures: a retrospective cohort study. Arch Orthop Trauma Surg 2019; 139:483-488. [PMID: 30523446 PMCID: PMC6420896 DOI: 10.1007/s00402-018-3088-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Indexed: 11/13/2022]
Abstract
INTRODUCTION A Dutch survey among orthopedic surgeons and trauma surgeons showed that almost 90% of the surgeons do not follow protocols regarding the weight bearing aftercare for tibial plateau fractures. Clinical studies comparing permissive weight bearing (PWB) versus restricted weight bearing (RWB) after surgically treated tibial plateau fractures are not available. The aim of this study was to inventory potential differences in quality of life and pain, and number of complications in patients with surgically treated tibial plateau fractures who followed a PWB regime, relative to those that followed a RWB regime. MATERIALS AND METHODS This retrospective cohort study included surgically treated trauma patients with tibial plateau fractures, who underwent rehabilitation according to PWB or RWB between 2005 and 2015. Data such as demographics, patient-reported quality of life and pain, and patient outcome were collected. RESULTS This cohort study included 91 patients with a tibial plateau fracture (31 and 60 patients in the PWB and RWB groups respectively). No significant between-group differences in either age or gender were found. However, a significant difference in fracture type was found between groups, (p = 0.04). No significant differences were found in either patient-reported SF-12 or VAS scores between the PWB group and RWB group. Time to full weight bearing was significantly shorter in the PWB than in the RWB group, i.e., 14.7 versus 20.7 weeks, (p = 0.02). No significant differences were found regarding postoperative complications between the PWB and the RWB groups, i.e., 6.5% versus 10.0%, respectively. CONCLUSION PWB after surgically treated tibial plateau fractures is safe and is related to a significantly reduced time to full weight bearing with no significant differences in patient-reported quality of life and pain or complication rates.
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Rizkallah M, Assi A, Otayek J, Saliby RM, Mekhael M, El Abiad R, Ghanem I. What's Important: Foundations of Orthopaedics-The "Multiple-of-Three Rule": Where Is the Evidence? J Bone Joint Surg Am 2018; 100:1165-1166. [PMID: 29975276 DOI: 10.2106/jbjs.17.01640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | - Ayman Assi
- Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon
| | - Joeffroy Otayek
- Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon
| | | | - Mario Mekhael
- Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon
| | - Rami El Abiad
- Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon.,Hôtel-Dieu de France University Hospital, Saint-Joseph University, Beirut, Lebanon
| | - Ismat Ghanem
- Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon.,Hôtel-Dieu de France University Hospital, Saint-Joseph University, Beirut, Lebanon
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De Boer AS, Van Lieshout EMM, Van Moolenbroek G, Den Hartog D, Verhofstad MHJ. The effect of time to post-operative weightbearing on functional and clinical outcomes in adults with a displaced intra-articular calcaneal fracture; A systematic review and pooled analysis. Injury 2018; 49:743-752. [PMID: 29496317 DOI: 10.1016/j.injury.2018.02.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 02/12/2018] [Accepted: 02/18/2018] [Indexed: 02/09/2023]
Abstract
BACKGROUND Post-operative weightbearing guidelines for displaced intra-articular calcaneal fractures (DIACF) have been pragmatically developed in the past, however hardly adapted to current health care insights. A period of six to nine weeks of non-weightbearing is usually recommended. It is unknown whether an earlier start of weightbearing is advisable. OBJECTIVES The primary aim was to evaluate the effect of time to post-operative weightbearing on Böhler's angle. Secondary aims were to determine the effect on functional outcome (e.g., The American Orthopedic Foot and Ankle Society Scale), post-operative pain score, complications (e.g., infections, nonunion, implant removal), and revision surgeries. Finally, the effect of bone void filling on these outcomes was investigated. DATA SOURCE A literature search was performed on January 24, 2017 in the Cochrane Library, Medline Ovid, Embase, Web of Science, Google Scholar, and CINAHL. LITERATURE SELECTION Studies reporting on operatively treated patients with a DIACF and time to weightbearing were eligible for inclusion. Studies were excluded when not reporting primary data, solely reporting on open fractures, bilateral fractures, or polytrauma patients. Based upon the time to starting partial weightbearing, patient cohorts were stratified into very early (0-4 weeks), early (4-6 weeks), intermediate (6-8 weeks), or late (8-12 weeks) start of partial weightbearing. DATA EXTRACTION Two investigators extracted data independently using a predefined data sheet. RESULTS After applying exclusion criteria, 72 studies remained eligible for analysis. Böhler's and Gissane's angles, calcaneal height, AOFAS, pain scores, and complications had overlapping confidence intervals in all weightbearing groups. CONCLUSION The adverse sequelae which are assumed to be associated with starting partial weightbearing already within six weeks after internal fixation of calcaneal fractures, is not supported by literature data. This systematic review suggests that early weightbearing does not result in impaired outcomes compared with more conservative weightbearing regimes.
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Affiliation(s)
- A Siebe De Boer
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.
| | - Gerson Van Moolenbroek
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.
| | - Dennis Den Hartog
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.
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Kalmet PHS, Meys G, V Horn YY, Evers SMAA, Seelen HAM, Hustinx P, Janzing H, Vd Veen A, Jaspars C, Sintenie JB, Blokhuis TJ, Poeze M, Brink PRG. Permissive weight bearing in trauma patients with fracture of the lower extremities: prospective multicenter comparative cohort study. BMC Surg 2018; 18:8. [PMID: 29391063 PMCID: PMC5796499 DOI: 10.1186/s12893-018-0341-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 01/25/2018] [Indexed: 11/29/2022] Open
Abstract
Background The standard aftercare treatment in surgically treated trauma patients with fractures around or in a joint, known as (peri)- or intra-articular fractures of the lower extremities, is either non-weight bearing or partial weight bearing. We have developed an early permissive weight bearing post-surgery rehabilitation protocol in surgically treated patients with fractures of the lower extremities. In this proposal we want to compare our early permissive weight bearing protocol to the existing current non-weight bearing guidelines in a prospective comparative cohort study. Methods/design The study is a prospective multicenter comparative cohort study in which two rehabilitation aftercare treatments will be contrasted, i.e. permissive weight bearing and non-weight bearing according to the AO-guideline. The study population consists of patients with a surgically treated fracture of the pelvis/acetabulum or a surgically treated (peri)- or intra-articular fracture of the lower extremities. The inclusion period is 12 months. The duration of follow up is 6 months, with measurements taken at baseline, 2,6,12 and 26 weeks post-surgery. Primary outcome measure: ADL with Lower Extremity Functional Scale. Outcome variables for compliance, as measured with an insole pressure measurement system, encompass peak load and step duration. Discussion This study will investigate the (cost-) effectiveness of a permissive weight bearing aftercare protocol. The results will provide evidence whether a permissive weight bearing protocol is more effective than the current non-weight bearing protocol. Trial registration The study is registered in the Dutch Trial Register (NTR6077). Date of registration: 01–09-2016.
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Affiliation(s)
- Pishtiwan H S Kalmet
- Department of Traumatology, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
| | - Guido Meys
- Adelante Rehabilitation Center, Hoensbroek, The Netherlands
| | | | - Silvia M A A Evers
- Maastricht University, School for Public Health and Primary Care: CAPHRI, Maastricht, The Netherlands
| | | | - Paul Hustinx
- Zuyderland Medical Center, Heerlen, The Netherlands
| | | | | | - Coen Jaspars
- Maxima Medical Center, Veldhoven, The Netherlands
| | | | - Taco J Blokhuis
- Department of Traumatology, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Martijn Poeze
- Department of Traumatology, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Peter R G Brink
- Department of Traumatology, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
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Arnold JB, Tu CG, Phan TM, Rickman M, Varghese VD, Thewlis D, Solomon LB. Characteristics of postoperative weight bearing and management protocols for tibial plateau fractures: Findings from a scoping review. Injury 2017; 48:2634-2642. [PMID: 29102370 DOI: 10.1016/j.injury.2017.10.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 10/10/2017] [Accepted: 10/28/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To identify and describe the characteristics of existing practices for postoperative weight bearing and management of tibial plateau fractures (TPFs), identify gaps in the literature, and inform the design of future research. METHODS Seven electronic databases and clinical trial registers were searched from inception until November 17th 2016. Studies were included if they reported on the surgical management of TPFs, had a mean follow-up time of ≥1year and provided data on postoperative management protocols. Data were extracted and synthesized according to study demographics, patient characteristics and postoperative management (weight bearing regimes, immobilisation devices, exercises and complications). RESULTS 124 studies were included involving 5156 patients with TPFs. The mean age across studies was 45.1 years (range 20.8-72; 60% male), with a mean follow-up of 34.9 months (range 12-264). The most frequent fracture types were AO/OTA classification 41-B3 (29.5%) and C3 (25%). The most commonly reported non-weight bearing time after surgery was 4-6 weeks (39% of studies), with a further 4-6 weeks of partial weight bearing (51% of studies), resulting in 9-12 weeks before full weight bearing status was recommended (55% of studies). Loading recommendations for initial weight bearing were most commonly toe-touch/<10kg (28%), 10kg-20kg (33%) and progressive (39%). Time to full weight bearing was positively correlated with the proportion of fractures of AO/OTA type C (r=0.465, p=0.029) and Schatzker type IV-VI (r=0.614, p<0.001). Similar rates of rigid (47%) and hinged braces were reported (58%), most frequently for 3-6 weeks (43% of studies). Complication rates averaged 2% of patients (range 0-26%) for abnormal varus/valgus and 1% (range 0-22%) for non-union or delayed union. CONCLUSIONS Postoperative rehabilitation for TPFs most commonly involves significant non-weight bearing time before full weight bearing is recommended at 9-12 weeks. Partial weight bearing protocols and brace use were varied. Type of rehabilitation may be an important factor influencing recovery, with future high quality prospective studies required to determine the impact of different protocols on clinical and radiological outcomes.
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Affiliation(s)
- John B Arnold
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Sansom Institute for Health Research, School of Health Sciences, University of South Australia, Adelaide, Australia
| | - Chen Gang Tu
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Port Road, Adelaide, SA, Australia
| | - Tri M Phan
- Hospital for Trauma and Orthopaedics, Ho Chi Minh, Vietnam
| | - Mark Rickman
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Port Road, Adelaide, SA, Australia; Centre for Orthopaedic and Trauma Research, Discipline of Orthopaedics and Trauma, University of Adelaide, Adelaide, Australia
| | - Viju Daniel Varghese
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Port Road, Adelaide, SA, Australia
| | - Dominic Thewlis
- Centre for Orthopaedic and Trauma Research, Discipline of Orthopaedics and Trauma, University of Adelaide, Adelaide, Australia
| | - Lucian B Solomon
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Port Road, Adelaide, SA, Australia; Centre for Orthopaedic and Trauma Research, Discipline of Orthopaedics and Trauma, University of Adelaide, Adelaide, Australia.
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Polat G, Karademir G, Akalan E, Aşık M, Erdil M. Patient compliance with touchdown weight bearing after microfracture treatment of talar osteochondral lesions. J Orthop Surg Res 2017; 12:46. [PMID: 28320425 PMCID: PMC5359809 DOI: 10.1186/s13018-017-0548-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 03/13/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was to prospectively evaluate the compliance of our patients with a touchdown weight bearing (without supporting any weight on the affected side by only touching the plantar aspect of the foot to the ground to maintain balance to protect the affected side from mechanical loading) postoperative rehabilitation protocol after treatment of talar osteochondral lesion (TOL). METHODS Fourteen patients, who had been treated with arthroscopic debridement and microfracture, were followed prospectively. The patients were evaluated for weight bearing compliance with using a stationary gait analysis and feedback system at the postoperative first day, first week, third week, and sixth week. RESULTS The mean visual analog scale (VAS) scores of the patients at the preoperative, postoperative first day, first week, third week, and sixth weeks were 5.5, 5.9, 3.6, 0.9, and 0.4, respectively. The decrease in VAS scores were statistically significant (p < 0.0001). First postoperative day revealed a mean value of transmitted weight of 4.08% ±0.8 (one non-compliant patient). The mean value was 4.34% ±0.8 at the first postoperative week (two non-compliant patients), 6.95% ±2.3 at the third postoperative week (eight non-compliant patients), and 10.8% ±4.8 at the sixth postoperative week (11 non-compliant patients). In the analysis of data, we found a negative correlation between VAS scores and transmitted weight (Kendall's tau b = -0.445 and p = 0.0228). CONCLUSIONS Although patients were able to learn and adjust to the touchdown weight bearing gait protocol during the early postoperative period, most patients became non-compliant when their pain was relieved. To prevent this situation of non-compliance, patients should be warned to obey the weight bearing restrictions, and patients should be called for a follow-up at the third postoperative week.
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Affiliation(s)
- Gökhan Polat
- Department of Orthopaedics and Traumatology, Istanbul University, Istanbul Medical Faculty, Çapa-Fatih, Istanbul, 34093, Turkey.
| | - Gökhan Karademir
- Department of Orthopaedics and Traumatology, Istanbul University, Istanbul Medical Faculty, Çapa-Fatih, Istanbul, 34093, Turkey
| | - Ekin Akalan
- Faculty of Science Health Physiotherapy & Rehab. Division, Istanbul University, Istanbul, Turkey
| | - Mehmet Aşık
- Department of Orthopaedics and Traumatology, Istanbul University, Istanbul Medical Faculty, Çapa-Fatih, Istanbul, 34093, Turkey
| | - Mehmet Erdil
- Department of Orthopaedics and Traumatology, Istanbul Medipol University, Istanbul, Turkey
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Greenhill DA, Poorman M, Pinkowski C, Ramsey FV, Haydel C. Does weight-bearing assignment after intramedullary nail placement alter healing of tibial shaft fractures? Orthop Traumatol Surg Res 2017; 103:111-114. [PMID: 28126324 DOI: 10.1016/j.otsr.2016.09.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 07/11/2016] [Accepted: 09/06/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION There is no consensus regarding postoperative weight-bearing (WB) assignment after treatment of tibial shaft fractures with an intramedullary nail. This study aims to determine if the postoperative WB assignment after tibia intramedullary nail placement alters healing. METHODS Closed AO type 42A fractures treated with a reamed statically-locked intramedullary nail over a 10-year period were retrospectively reviewed from injury at 2, 3, 6, 9 and 12 month intervals until union or revision. Patients were categorized according to postoperative weight-bearing assignment: weight-bearing-as-tolerated (WBAT) or non-weight-bearing (NWB). Patients with additional diagnoses that confound routine fracture healing were excluded. Postoperative radiographic union scores for tibial fractures (RUST), coronal/sagittal angulations, and length were compared between different weight-bearing groups. Union was defined as a RUST≥10 at a painless fracture site. RESULTS A total of 83 patients achieved union (32 WBAT, 51 NWB). Both WB groups had similar preoperative demographics. Average age was 37±13 years and follow-up averaged 1.3±0.2 years. There were no significant differences in average time to radiographic union between NWB versus WBAT groups (5.5 vs. 6.1 months, respectively; P=0.208) nor radiographic healing at 2, 3, and 6-month intervals (P=0.631). There were two nonunions and one fracture shortened in the NWB group. There were no reoperations for symptomatic or broken hardware in either cohort. CONCLUSION Immediate WBAT after statically-locked intramedullary nail placement in simple tibial shaft fractures does not alter the time until or course of radiographic union. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- D A Greenhill
- Department of orthopaedic surgery and sports medicine, Temple university hospital, 3401N, Broad street, 19140 Philadelphia, USA.
| | - M Poorman
- Temple university school of medicine, 3500N, Broad street, 19140 Philadelphia, USA
| | - C Pinkowski
- Temple university school of medicine, 3500N, Broad street, 19140 Philadelphia, USA
| | - F V Ramsey
- Temple university school of medicine, 3500N, Broad street, 19140 Philadelphia, USA
| | - C Haydel
- Department of orthopaedic surgery and sports medicine, Temple university hospital, 3401N, Broad street, 19140 Philadelphia, USA
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van der Vusse M, Kalmet PHS, Bastiaenen CHG, van Horn YY, Brink PRG, Seelen HAM. Is the AO guideline for postoperative treatment of tibial plateau fractures still decisive? A survey among orthopaedic surgeons and trauma surgeons in the Netherlands. Arch Orthop Trauma Surg 2017; 137:1071-1075. [PMID: 28534233 PMCID: PMC5511292 DOI: 10.1007/s00402-017-2718-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The standard aftercare treatment (according to the AO guideline) for surgically treated trauma patients with fractures of the tibial plateau is non-weight bearing or partial weight bearing for 10-12 weeks. The purpose of this study was to investigate the current state of practice among orthopaedic surgeons and trauma surgeons in choosing the criteria and the time period of restricted weight bearing after surgically treated tibial plateau fractures. MATERIALS AND METHODS A web-based survey was distributed among members of the Dutch Trauma Society and Dutch Orthopaedic Society to identify the most commonly applied protocols in terms of the post-operative initiation and level of weight bearing in patients with tibial plateau fractures. RESULTS One hundred and eleven surgeons responded to the survey. 72.1% of the respondents recommended starting weight bearing earlier than the 12 weeks recommended by the AO guideline; 11.7% recommended starting weight bearing immediately, 4.5% after 2 weeks and 55.9% after 6 weeks. Moreover, 88.7% of the respondents reported deviating from their own local protocol. There is little consensus about the definition of 100% weight bearing and how to build up weight bearing over time. CONCLUSION This study demonstrates that consensus about the weight bearing aftercare for tibial plateau fractures are limited. A large majority of surgeons do not follow the AO guideline or their own local protocol. More transparent criteria and predictors are needed to design optimal weight-bearing regimes for the aftercare of tibial plateau fractures.
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Affiliation(s)
- M. van der Vusse
- Adelante Rehabilitation Centre, Hoensbroek, The Netherlands ,Laurentius Hospital Roermond, Roermond, The Netherlands
| | - P. H. S. Kalmet
- Department of Traumatology, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | | | - Y. Y. van Horn
- Adelante Rehabilitation Centre, Hoensbroek, The Netherlands
| | - P. R. G. Brink
- Department of Traumatology, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - H. A. M. Seelen
- Adelante Rehabilitation Centre, Hoensbroek, The Netherlands ,Research School CAPHRI, Maastricht University, Maastricht, The Netherlands
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Tan EW, Sirisreetreerux N, Paez AG, Parks BG, Schon LC, Hasenboehler EA. Early Weightbearing After Operatively Treated Ankle Fractures: A Biomechanical Analysis. Foot Ankle Int 2016; 37:652-8. [PMID: 26802427 DOI: 10.1177/1071100715627351] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND No consensus exists regarding the timing of weightbearing after surgical fixation of unstable traumatic ankle fractures. We evaluated fracture displacement and timing of displacement with simulated early weightbearing in a cadaveric model. METHODS Twenty-four fresh-frozen lower extremities were assigned to Group 1, bimalleolar ankle fracture (n=6); Group 2, trimalleolar ankle fracture with unfixed small posterior malleolar fracture (n=9); or Group 3, trimalleolar ankle fracture with fixed large posterior malleolar fracture (n=9) and tested with axial compressive load at 3 Hz from 0 to 1000 N 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 all groups was significantly less than 1 mm (P < .05). Group 1 displacement of the lateral and medial malleolus fracture was 0.1±0.1 mm and 0.4±0.4 mm, respectively. Group 2 displacement of the lateral, medial, and posterior malleolar fracture was 0.6±0.4 mm, 0.5±0.4 mm, and 0.5±0.6 mm, respectively. Group 3 displacement of the lateral, medial, and posterior malleolar fracture was 0.1±0.1 mm, 0.5±0.7 mm, and 0.5±0.4 mm, respectively. The majority of displacement (64.0% to 92.3%) occurred in the first 50 000 cycles. There was no correlation between fracture displacement and bone mineral density. CONCLUSION No significant fracture displacement, no hardware failure, and no new fractures occurred in a cadaveric model of early weightbearing in unstable ankle fracture after open reduction and internal fixation. CLINICAL RELEVANCE This study supports further investigation of early weightbearing postoperative protocols after fixation of unstable ankle fractures.
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Affiliation(s)
- Eric W Tan
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Adrian G Paez
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Brent G Parks
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Lew C Schon
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Erik A Hasenboehler
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Hoyt BW, Pavey GJ, Pasquina PF, Potter BK. Rehabilitation of Lower Extremity Trauma: a Review of Principles and Military Perspective on Future Directions. CURRENT TRAUMA REPORTS 2015. [DOI: 10.1007/s40719-014-0004-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Song JQ, Dong F, Li X, Xu CP, Cui Z, Jiang N, Jia JJ, Yu B. Effect of treadmill exercise timing on repair of full-thickness defects of articular cartilage by bone-derived mesenchymal stem cells: an experimental investigation in rats. PLoS One 2014; 9:e90858. [PMID: 24595327 PMCID: PMC3940955 DOI: 10.1371/journal.pone.0090858] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 02/06/2014] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Current medical practice for the treatment of articular cartilage lesions remains a clinical challenge due to the limited self-repair ability of articular cartilage. Both experimental and clinical researches show that moderate exercise can improve articular cartilage repair process. However, optimal timing of moderate exercise is unclear. We aimed to evaluate the effect of timing of moderate treadmill exercise on repair of full-thickness defects of articular cartilage. DESIGN Full-thickness cartilage defects were drilled in the patellar groove of bilateral femoral condyles in a total of 40 male SD rats before they were randomly assigned into four even groups. In sedentary control (SED) group, no exercise was given; in 2-week (2W), 4-week (4W) and 8-week groups, moderate treadmill exercise was initiated respectively two, four and eight weeks after operation. Half of the animals were sacrificed at week 10 after operation and half at week 14 after operation. Femoral condyles were harvested for gross observation and histochemical measurement by O'Driscoll scoring system. Collagen type II was detected by immunohistochemistry and mRNA expressions of aggrecan and collagen type II cartilage by RT-PCR. RESULTS Both 10 and 14 weeks post-operation, the best results were observed in 4W group and the worst results appeared in 2W group. The histochemistry scores and the expressions of collagen type II and aggrecan were significantly higher in 4W group than that in other three groups (P<0.05). CONCLUSIONS Moderate exercise at a selected timing (approximately 4 weeks) after injury can significantly promote the healing of cartilage defects but may hamper the repair process if performed too early while delayed intervention by moderate exercise may reduce its benefits in repair of the defects.
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Affiliation(s)
- Jin-qi Song
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
| | - Fu Dong
- Department of Orthopaedics, Beihai People's Hospital of Guangxi Province, Bei Hai, Guangxi Province, China
| | - Xue Li
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
| | - Chang-peng Xu
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
| | - Zhuang Cui
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
| | - Nan Jiang
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
| | - Jun-jie Jia
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
| | - Bin Yu
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
- Key Laboratory of Bone and Cartilage Regenerative Medicine of Guangdong Province, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
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