Early rehabilitation following less invasive surgical stabilisation plate fixation for distal femoral fractures

Failure of Less-Invasive Stabilization System (LISS) plating for periprosthetic distal femur fractures: Three case reports

RATIONALE

Less-Invasive Stabilization System (LISS) plate is an internal fixation commonly used for the periprosthetic distal femur fractures. Failure associated with LISS plate has been rarely reported, and the reasons for LISS plate failure are multitudinous. Various advantages have been reported, but failures continue.

PATIENT CONCERNS

We present 3 cases illustrating the failure of Less-Invasive Stabilization System (LISS) plating for periprosthetic distal femur fractures. The shaft screws of the LISS plate broke in 2 cases, and the plate placement was incorrect in 1 case. Early weight bearing, obesity, osteoporosis, and lateral collateral ligament injury due to incorrect plate placement constituted the etiologies of LISS plate failure.

DIAGNOSIS

Failure of Less-Invasive Stabilization System (LISS) plating for periprosthetic distal femur fractures after Total knee arthroplasty.

INTERVENTIONS

Three patients underwent Less-Invasive Stabilization System plates removal with replacement of the total knee arthroplasty revision surgery with rotating hinged knee prosthesis.

OUTCOMES

After completing the total knee arthroplasty revision surgery, all patients underwent regular follow-up examinations. Case 2 could walk unaided, without pain, final union was confirmed for both case 1 and case 3.

CONCLUSION

Less-Invasive Stabilization System (LISS) plate provides satisfactory results in periprosthetic fractures after Total knee arthroplasty (TKA). The LISS plate has many advantages, but failures continue to occur. The causes for failure were early weight bearing, obesity, osteoporosis, and lateral collateral ligament (LCL) injury due to incorrect plate placement in our series. We recommend that protection or properly delay of weight-bearing, active anti-osteoporosis treatment, and intraoperative fluoroscopy are the effective methods to avoid failure.

Developing a multidisciplinary rehabilitation package following hip fracture and testing in a randomised feasibility study: Fracture in the Elderly Multidisciplinary Rehabilitation (FEMuR)

BACKGROUND

Proximal femoral fracture is a major health problem in old age, with annual UK health and social care costs of £2.3B. Rehabilitation has the potential to maximise functional recovery and maintain independent living, but evidence of clinical effectiveness and cost-effectiveness is lacking.

OBJECTIVES

To develop an enhanced community-based rehabilitation package following surgical treatment for proximal femoral fracture and to assess acceptability and feasibility for a future definitive randomised controlled trial (RCT) and economic evaluation.

DESIGN

Phase I - realist review, survey and focus groups to develop the rehabilitation package. Phase II - parallel-group, randomised (using a dynamic adaptive algorithm) feasibility study with focus groups and an anonymised cohort study.

SETTING

Recruitment was from orthopaedic wards of three acute hospitals in the Betsi Cadwaladr University Health Board, North Wales. The intervention was delivered in the community following hospital discharge.

PARTICIPANTS

Older adults (aged ≥ 65 years) who had received surgical treatment for hip fracture, lived independently prior to fracture, had mental capacity (assessed by the clinical team) and received rehabilitation in the North Wales area.

INTERVENTIONS

Participants received usual care (control) or usual care plus an enhanced rehabilitation package (intervention). Usual care was variable and consisted of multidisciplinary rehabilitation delivered by the acute hospital, community hospital and community services depending on need and availability. The intervention was designed to enhance rehabilitation by improving patients' self-efficacy and increasing the amount and quality of patients' practice of physical exercise and activities of daily living. It consisted of a patient-held information workbook, a goal-setting diary and six additional therapy sessions.

MAIN OUTCOME MEASURES

The primary outcome measure was the Barthel Activities of Daily Living (BADL) index. The secondary outcome measures included the Nottingham Extended Activities of Daily Living (NEADL) scale, EuroQol-5 Dimensions, ICEpop CAPability measure for Older people, General Self-Efficacy Scale, Falls Efficacy Scale - International (FES-I), Self-Efficacy for Exercise scale, Hospital Anxiety and Depression Scale (HADS) and service use measures. Outcome measures were assessed at baseline and at 3-month follow-up by blinded researchers.

RESULTS

Sixty-two participants were recruited (23% of those who were eligible), 61 were randomised (control, n = 32; intervention, n = 29) and 49 (79%) were followed up at 3 months. Compared with the cohort study, a younger, healthier subpopulation was recruited. There were minimal differences in most outcomes between the two groups, including the BADL index, with an adjusted mean difference of 0.5 (Cohen's d = 0.29). The intervention group showed a medium-sized improvement on the NEADL scale relative to the control group, with an adjusted mean difference between groups of 3.0 (Cohen's d = 0.63). There was a trend for greater improvement in FES-I and HADS in the intervention group, but with small effect sizes, with an adjusted mean difference of 4.2 (Cohen's d = 0.31) and 1.3 (Cohen's d = 0.20), respectively. The cost of delivering the intervention was £231 per patient. There was a possible small relative increase in quality-adjusted life-years in the intervention group. No serious adverse events relating to the intervention were reported.

CONCLUSIONS

Trial methods were feasible in terms of eligibility, recruitment and retention, although recruitment was challenging. The NEADL scale was more responsive than the BADL index, suggesting that the intervention could enable participants to regain better levels of independence compared with usual care. This should be tested in a definitive Phase III RCT. There were two main limitations of the study: the feasibility study lacked power to test for differences between the groups and a ceiling effect was observed in the primary measure.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN22464643.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 44. See the NIHR Journals Library for further project information.

Development of an evidence-based complex intervention for community rehabilitation of patients with hip fracture using realist review, survey and focus groups

OBJECTIVES

To develop an evidence and theory-based complex intervention for improving outcomes in elderly patients following hip fracture.

DESIGN

Complex-intervention development (Medical Research Council (MRC) framework phase I) using realist literature review, surveys and focus groups of patients and rehabilitation teams.

SETTING

North Wales.

PARTICIPANTS

Surveys of therapy managers (n=13), community and hospital-based physiotherapists (n=129) and occupational therapists (n=68) throughout the UK. Focus groups with patients (n=13), their carers (n=4) and members of the multidisciplinary rehabilitation teams in North Wales (n=13).

RESULTS

The realist review provided understanding of how rehabilitation interventions work in the real-world context and three programme theories were developed: improving patient engagement by tailoring the intervention to individual needs; reducing fear of falling and improving self-efficacy to exercise and perform activities of daily living; and coordination of rehabilitation delivery. The survey provided context about usual rehabilitation practice; focus groups provided data on the experience, acceptability and feasibility of rehabilitation interventions. An intervention to enhance usual rehabilitation was developed to target these theory areas comprising: a physical component consisting of six additional therapy sessions; and a psychological component consisting of a workbook to enhance self-efficacy and a patient-held goal-setting diary for self-monitoring.

CONCLUSIONS

A realist approach may have advantages in the development of evidence-based interventions and can be used in conjunction with other established methods to contribute to the development of potentially more effective interventions. A rehabilitation intervention was developed which can be tested in a future randomised controlled trial (MRC framework phases II and III).

TRIAL REGISTRATION NUMBER

ISRCTN22464643, Pre-results.