Correlation of psychomotor findings and the ability to partially weight bear

Influence of Weight Bearing on Postoperative Complications after Surgical Treatment of the Lower Extremity

PURPOSE

In order to prevent implant failure and secondary fracture dislocation, it is often recommended that patients perform partial weight-bearing after surgery of the lower extremity. Previous examinations showed that patients are often not able to follow these instructions. In this study, patients who had undergone surgery of the lower extremity were studied in order to analyze whether incorrect loading influenced the number and severity of complications.

METHODS

Fifty-one patients were equipped with electronic shoe insoles, which measure loading and other parameters. The measurement period was 24 to 102 hours. Median duration of follow-up was 490 days. The primary outcome parameter was postoperative complications leading to revision surgery. Statistical analysis was performed using the chi-square and Fisher exact tests with significance set at a p < 0.05.

RESULTS

Seven out of fifty-one patients had postoperative complications. Four wound complications, one implant failure, chronic instability after fracture of the tibia, and one implant loosening of a hip prosthesis were recorded. In total, 26 of 39 patients were not able to follow the postoperative instructions. Five of the twenty-six patients with difficulties in partial weight-bearing suffered a postoperative complication. In comparison, only 2 of the other 25 patients were affected. There was no statistically significant correlation between high weight-bearing and occurrence of complications (p = 0.29).

CONCLUSION

Most of the patients were unable to follow the surgeon's instructions for partial weight-bearing. Excessive loading did not seem to influence the number and severity of postoperative complications, especially regarding implant failure. Therefore, we should continue with measurements and reevaluate the "partial weight-bearing doctrine".

Comparison of Percutaneous Screw Fixation to Open Reduction and Internal Fixation in Acetabular Fractures: A Matched Pair Study Regarding the Short-Term Rate of Conversion to Total Hip Arthroplasty and Functional Outcomes

Closed reduction and percutaneous internal fixation (CRPIF) for acetabular fractures was introduced as a less invasive alternative to open reduction and internal fixation (ORIF) for moderately displaced fractures. Currently, comparisons of ORIF and CRPIF outcomes are rare. Twenty-three patients treated with CRPIF were matched with patients treated with ORIF based on sex, age, and fracture classification. Surgery-dependent and -independent factors of the in-hospital stay, the conversion rate to total hip arthroplasty (THA), and quality of life were assessed. The ORIF group had a higher preoperative fracture step (p = 0.04) and gull wing sign (p = 0.003) compared with the CRPIF group. Postoperatively, the gap and step size were not significantly different between the groups (p > 0.05). CRPIF required less time (p < 0.0001) and transfusions (p = 0.009) and showed fewer complications (p = 0.0287). Four patients were converted to THA (CRPIF, n = 1; ORIF, n = 3; p = 0.155) because of posttraumatic osteoarthritis. Functional outcomes and pain were similar in both groups (p > 0.05). The present study revealed less blood loss and a lesser extent of reduction in patients treated with CRPIF than in those treated with ORIF. The rates of conversion to THA and functional outcomes did not differ between CRPIF and ORIF. CRPIF appeared to be a valuable treatment option for selected patients.

Analysis of partial weight bearing after surgical treatment in patients with injuries of the lower extremity

INTRODUCTION

After surgical treatment of injuries of the lower extremity, partial weight bearing is often suggested until soft tissue consolidation. It is doubtful, if this recommendation can be implemented, even in the case that a patient is performing partial weight bearing with a physical therapist. Consequently the question remains, if patients are able to implement partial weight bearing after surgery and which factors favor incompliance.

MATERIALS AND METHODS

49 patients, who underwent surgical treatment after injuries of the lower extremity, were equipped with electronic shoe insoles on both sides. Different weight bearing instructions were given depending on the type of injury and surgery (full weight bearing vs. 20 kg weight bearing vs. non-weight bearing). Besides loading, other factors like age, gender, weight and physical activity were evaluated. Statistical analysis was performed using Chi-square and Fisher's exact test with significance set at a p value < 0.05.

RESULTS

25 of the 40 patients, who had to perform non- or partial weight bearing, were not able to follow postoperative instructions (compliance rate 37.5%). The average loading of the whole collective was 32.6 kg (4.8-109.2 kg). The specification of loading had no statistically significant influence on real loading (p-value 0.39). Elderly patients were less able to follow instructions than younger patients (36 vs 30.2 kg). Physically active compared to non-active patients overloaded their injured extremity (37.8 vs 28.7 kg). Patients with a high body mass index (BMI) encountered more difficulties to perform partial weight bearing than lightweight patients (36.9 vs 25.1 kg).

CONCLUSIONS

Most patients were not able to follow loading limitation, even a few days after surgery and even if the patients were trained by a physiotherapist. Excessive weight bearing-related complications should be evaluated.

Mortality, complications and long-term functional outcome in elderly patients with fragility fractures of the acetabulum

Background

Early operative treatment of acetabulum fractures in geriatric patients has been suggested to reduce pain and allow for earlier mobilization. The aim of this study was to determine mortality, complications and functional outcome after operative and non-operative treatment.

Methods

Patients aged ≥60 years with operative treatment of low-energy fragility fracture of the acetabulum from 2009 to 2016 and a follow-up of at least 24 months were identified. The patients were contacted by phone and a modified Merle d’Aubigné score was obtained. If patients or their relatives were not available for follow-up, mortality data was assessed using a national social insurance database.

Results

One hundred seventy-six patients (mean age 78, SD 10 years; 73 female) were available for analysis of mortality data. At final follow-up (68 months, SD 26, range, 24 to 129), 99/176 patients (56.3%) had deceased. One-year-mortality was 25.0% and 2-year mortality 35.8%. Type of treatment (non-operative vs. operative) did not affect mortality at 1 and 2 years (p = .65 and p = .10). Hospital-acquired infections were observed in 31/176 cases (17.6%), thromboembolic events and delirium in 6 patients (3.4%). In-hospital mortality was 5.7%. Patients who underwent operative treatment were more likely to have an in-hospital infection (p = .02) but less likely to sustain thromboembolic events (p = .03).

The mean hospital stay was 14 days (SD 10 days, range, 1 to 66). Patients with operative treatment were longer hospitalized than patients with non-operative treatment (p < .001).

The rate of secondary conversions to THA was 12.4%, this was not affected by initial treatment.

The mean modified Merle d’Aubigné Score of those patients available for a final follow-up (n = 47; follow-up 56 months, SD 28, range, 24 to 115) was 14/18 points, SD 3 (range 7 to 18). Functional results at final follow-up between operatively and non-operatively treated patients were without difference.

Conclusions

All-cause mortality and in-hospital complications are high among geriatric patients with low-energy fractures of the acetabulum even when treated operatively. Secondary conversion rates to THA are similar to those seen in younger patients. Mid-term functional outcome in those surviving is fair.

Screw fixation of ACPHT acetabular fractures offers sufficient biomechanical stability when compared to standard buttress plate fixation

BACKGROUND

Geriatric acetabular fractures require fixation with sufficient primary stability to allow for immediate full-weight bearing. Minimally-invasive procedures would be desirable in order to keep perioperative morbidity low. The purpose of this study was to compare the biomechanical strength of lag screw-only fixation of anterior column posterior hemi-transverse (ACPHT) acetabular fractures to standard anatomical plate fixation.

METHODS

Standardized ACPHT fractures were created in fourth generation synthetic pelvis models and stabilized by either an anatomical buttress plate (n = 4) or by a screw-only construct (n = 4). In a validated setup, a cyclic loading protocol was applied with increasing axial force (3200 cycles, 175 N to 2250 N). Construct survival, acetabular fracture motion, and mode of failure were assessed.

RESULTS

The median number of cycles needed until failure of the construct occurred was 2304 cycles (range, 2020 to 2675) in the plate fixation group and 3200 cycles (range, 3101 to 3200) for the screw fixation constructs (p = .003). With regard to energy absorbed until failure, the plate fixation group resisted to 1.57 × 10⁶ N*cycles (range, 1.21 × 10⁶ to 2.14 × 10⁶) and the screw fixation group to 3.17 × 10⁶ N*cycles (range, 2.92 × 10⁶ to 3.17 × 10⁶; p = .001). All plate fixation specimens failed with a break-out of the posterior-column screw in the quadrilateral wing of the anatomical plate within a maximum load of 1750 N while the screw fixation constructs all survived loading of at least 2100 N. Acetabular fracture gap motion, acetabular rim angle, and medial femoral head subluxation as measures of fracture displacement were all not different between the two groups (p > 0.1).

CONCLUSIONS

In this in vitro biomechanical study, screw-only fixation of an ACPHT acetabular fracture resulted in at least as good construct survival as seen for standard buttress plate fixation. Both methods resisted sufficiently to forces that would be expected under physiologic conditions.

Orthopedic inpatients’ ability to accurately reproduce partial weight bearing orders

Partial weight bearing is often prescribed for patients with orthopedic injuries. Patients’ ability to accurately reproduce partial weight bearing orders is variable, and its impact on clinical outcomes is unknown. This observational study measured patients’ ability to reproduce partial weight bearing orders, factors influencing this, patients’ and physiotherapists’ ability to gauge partial weight bearing accuracy, and the effect of partial weight bearing accuracy on long-term clinical outcomes. Fifty-one orthopedic inpatients prescribed partial weight bearing were included. All received standard medical/nursing/physiotherapy care. Physiotherapists instructed patients in partial weight bearing using the hand-under-foot, bathroom scales, and/or verbal methods of instruction. Weight bearing was measured on up to 3 occasions during hospitalization using a force-sensitive insole. Factors that had the potential to influence partial weight bearing accuracy were recorded. Patients and their physiotherapists rated their perception of partial weight bearing accuracy. Three-month clinical follow-up data were retrieved from medical records. The majority of patients (72% or more) exceeded their target load, with mean peak weight bearing as high as 19.3 kg over target load (285% of target load). Weight bearing significantly increased over the 3 measurement occasions (P<.001) and was significantly associated with greater body weight (P=.04). Patients and physiotherapists were unable to accurately gauge partial weight bearing accuracy. The incidence of clinically important complications at 3 months was 9% and not significantly associated with partial weight bearing accuracy during hospitalization (P≥.45). Patients are unable to accurately reproduce partial weight bearing orders when trained with the hand-under-foot, bathroom scales, or verbal methods of instruction.