Study protocol to examine the effects of acute exercise on motor learning and brain activity in children with developmental coordination disorder (ExLe-Brain-DCD).

INTRODUCTION: Developmental coordination disorder (DCD) is one of the most prevalent pediatric chronic conditions. Without proper intervention, significant delays in motor skill performance and learning may persist until adulthood. Moderate-to-vigorous physical exercise has been proven to improve motor learning (adaptation and consolidation) in children with or without disorders. However, the effect of a short bout of physical exercise on motor adaptation and consolidation in children with DCD has not been examined. Furthermore, the role of perceptual-motor integration and attention as mediators of learning has not been examined via neuroimaging in this population. OBJECTIVES: Therefore, the primary aims of this project will be to compare children with and without DCD to (a) examine the effect of acute exercise on motor learning (adaptation and consolidation) while performing a rotational visuo-motor adaptation task (rVMA), and (b) explore cortical activation in the dorsolateral- and ventrolateral-prefrontal cortex areas while learning the rVMA task under rest or post-exercise conditions. METHODS: One hundred twenty children will be recruited (60 DCD, 60 controls) and within-cohort randomly assigned to either exercise (13-minute shuttle run task) or rest prior to performing the rVMA task. Adaptation and consolidation will be evaluated via two error variables and three retention tests (1h, 24h and 7 days post adaptation). Cortical activation will be registered via functional near-infrared spectroscopy (fNIRS) during the baseline, adaptation, and consolidation. DISCUSSION: We expect to find exercise benefits on motor learning and attention so that children with DCD profiles will be closer to those of children with typical development. The results of this project will provide further evidence to: (a) better characterize children with DCD for the design of educational materials, and (b) establish acute exercise as a potential intervention to improve motor learning and attention.

A single plain ring is not associated with increased bacterial load on hands: An experimental study among healthcare worker students undertaking mock surgery.

BACKGROUND: Adequate hand hygiene is considered as one of the most effective strategies in healthcare-related infection prevention. The potential negative effect of rings in hand disinfection and thus, in increased nosocomial infections rates is still controversial. Therefore, the present study was designed with the purpose of examining if rings frequently exposed to surgical scrubbing were associated or not with increased bacterial counts. METHODS: 32 volunteers were randomized into 4 groups: A (no rings), B (participants wore a ring), C (no rings and performed surgical scrubbing with chlorhexidine every 48 h) and D (participants wore a ring and performed surgical scrubbing every 48 h). Glove juice samples were obtained at day 0 (T0) and after a 90-min mock-surgery on day 14 (T1). Quantitative (number of UFC/mL) and qualitative data (microorganism type) were collected as study variables. RESULTS: All groups were comparable at T0. All ring carriers obtained negative cultures at T1. Ring presence was not associated with higher bacterial counts; comparisons between A vs B groups and C vs D groups showed no statistically significant differences (p = 0.076 and 1.000). T1 negative cultures were more frequent in participants performing surgical scrubbing every second day (93.8 % vs 75 %), although this difference did not reach statistical significance (p = 0.332). CONCLUSIONS: The presence of single plain ring does not seem to be associated with an increased hand bacterial load. Regular surgical scrubbing with chlorhexidine impregnated sponges reduces bacterial contamination of hands, even in the presence of plain rings.

Skin sensory alteration and kneeling ability following cruciate retaining total knee arthroplasty are not affected by the incision position: A randomised controlled trial of simultaneous bilateral surgery.

PURPOSE: The purpose of this randomised controlled trial was to assess the impact of skin incision location on the patients' ability to kneel. METHODS: A total of 29 patients undergoing bilateral total knee arthroplasty (58 knees) were randomised to receive a lateral or midline incision, with the contralateral limb receiving the alternative option. Cruciate retaining implants were used in all cases by three experienced arthroplasty surgeons. The primary outcome measures assessed functional ability to kneel using an innovative five-point kneeling scale, preferred knee to kneel on and the area of cutaneous sensory loss around the incision at 6 weeks, 6 months and 12 months. Secondary outcome measures were the OKS, KOOS JR, FJS and EQ5D patient reported outcome measures (PROMS), length of surgical scar, overall knee preference and range of motion (ROM). RESULTS: There were no significant differences between the two groups for any primary or secondary outcome measures. Flexion range however, had a significant positive correlation with kneeling score (r = 0.335, p = 0.010). The kneeling score increased at each time point after surgery and was significantly greater at 12 months than preoperatively (2.7 v 3.5, p = 0.015). The area of sensory loss lateral to the incision was significantly less at 6 and 12 months than at 6 weeks (43.6cm2 and 40.1cm2 v 84.1cm2, p < 0.0001). CONCLUSION: The ability to kneel following cruciate retaining total knee arthroplasty is not affected by the incision position but by time and flexion range. TKA improves the ability to kneel by 12 months post-surgery. Sensory loss lateral to the incision reduces with time. LEVEL OF EVIDENCE: Therapeutic Level 2.

Patient-reported outcome measures for patellofemoral disorders: a systematic review.

INTRODUCTION: Patellofemoral conditions include, but are not limited to, anterior knee pain syndrome and patellar instability. Patients and surgeons may find it difficult to identify the specific source of the symptoms and clinical scenarios, so patient-reported outcome measures (PROMs) may be a useful diagnostic aid. There are a number of available PROMs for patellofemoral conditions, which are often used indistinctly. This systematic review explores the available PROMs for patellofemoral conditions, their use and methodological quality. METHODS: A systematic review was conducted, searching for scientific articles relating to PROMs in patellofemoral conditions, from inception to July 2022. Scoring systems including physician-directed or imagining assessment were not included. All types of conditions in the patellofemoral joint were considered. RESULTS: Twenty-two relevant PROMs were encountered, divided into four categories: eight PROMs for anterior knee pain syndrome, five for patellar instability, four for other patellofemoral conditions and five for non-specific PROMs. CONCLUSIONS: While many PROMs have been found used in patellofemoral research, only few of them have showed sufficient methodological quality. In addition, PROMs employed in PF literature are often inaccurately chosen. This review may help authors to better understand the characteristics of specific patellofemoral PROMs, in order to select the more appropriate and recommended ones. LEVEL OF EVIDENCE: Level II.

Children's strategies in drop-landing.

Introduction: Landing is a critical motor skill included in many activities performed in the natural environment by young children. Yet, landing is critically relevance to ensure proper stability and reduce injury. Furthermore, landing is an integral part of many fundamental motor skills which have been linked to greater physical activity, sport participation, and perceived competence in children. Our aim was to examine the drop-landing strategies of young children focusing on the lower extremity with a multi-variant approach. Methods: Forty-four children divided into four age groups (G1:3-4.5 y, G2:4.5-6 y, G3:6-7.5 y, G4:7.5-9 y) performed 20 drop-land trials in four different conditions: predictable stationary landing, running to the left, to the right, and stay in place. Fifteen reflective markers, two force plates, and ten surface electromyography (sEMG) sensors were used to collect data. MANOVAs (Group x Condition) were conducted separately for the kinematic, kinetic, and sEMG variables. Results: Only significant group effects were found (kinematic MANOVA p = 0.039, kinetic MANOVA p = 0.007, and sEMG MANOVA p = 0.012), suggesting that younger groups (G1, G2) differed to the older groups (G3, G4). G1 showed less knee flexion and slower ankle dorsi-flexion during the braking phase compared to G3, while G2 presented smaller ankle dorsi-flexion at the braking phase and smaller ankle range of motion than G3. Overall kinetic variables analysis showed a group difference but no group differences for any single kinetic variable alone was found. Regarding sEMG, G1 during the flight phase exhibited longer tibialis anterior and hamstrings activity than G3 and G3 & G4, respectively; and an earlier start of the hamstrings' impact burst than G4. In addition, distal to proximal control was primarily used by all groups to coordinate muscle activity (in response to impact) and joint motion (after impact). Discussion: Perhaps a developmental critical point in landing performance exists at 4-5 years of age since G1 presented the largest differences among the groups. This suggests that to improve landing strategies could start around this age. Future studies should examine if playground environments that include equipment conducive to landing and practitioners in the kindergarten schools are adequate vehicles to empower this type of intervention.

Can exercise shape your brain? A review of aerobic exercise effects on cognitive function and neuro-physiological underpinning mechanisms.

It is widely accepted that physical exercise can be used as a tool for the prevention and treatment of various diseases or disorders. In addition, in the recent years, exercise has also been successfully used to enhance people's cognition. There is a large amount of research that has supported the benefits of physical exercise on human cognition, both in children and adults. Among these studies, some have focused on the acute or transitory effects of exercise on cognition, while others have focused on the effects of regular physical exercise. However, the relation between exercise and cognition is complex and we still have limited knowledge about the moderators and mechanisms underlying this relation. Most of human studies have focused on the behavioral aspects of exercise-effects on cognition, while animal studies have deepened in its possible neuro-physiological mechanisms. Even so, thanks to advances in neuroimaging techniques, there is a growing body of evidence that provides valuable information regarding these mechanisms in the human population. This review aims to analyze the effects of regular and acute aerobic exercise on cognition. The exercise-cognition relationship will be reviewed both from the behavioral perspective and from the neurophysiological mechanisms. The effects of exercise on animals, adult humans, and infant humans will be analyzed separately. Finally, physical exercise intervention programs aiming to increase cognitive performance in scholar and workplace environments will be reviewed.

Gymnastics Experience Enhances the Development of Bipedal-Stance Multi-Segmental Coordination and Control During Proprioceptive Reweighting.

Performance and control of upright bipedal posture requires a constant and dynamic integration of relative contributions of different sensory inputs (i. e., sensory reweighting) to enable effective adaptations as individuals face environmental changes and perturbations. Children with gymnastic experience showed balance performance closer to that of adults during and after proprioceptive alteration than children without gymnastic experience when their center of pressure (COP) was analyzed. However, a particular COP sway can be achieved through performing and coordinating different postural movements. The aim of this study was to assess how children and adults of different gymnastic experience perform and control postural movements while they have to adjust balance during and after bilateral tendon vibration. All participants were equipped with spherical markers attached to their skin and two vibrators strapped over the Achilles tendons. Bipedal stance was performed in three 45-s trials in two visual conditions (eyes open, EO, and eyes closed, EC) ordered randomly in which vibration lasted 10 s. Posture movements were analyzed by a principal component analysis (PCA) calculated on normalized and weighted markers coordinates. The relative standard deviation of each principal movement component (principal position, PP-rSTD) quantified its contribution to the whole postural movements, i.e., quantified the coordinative structure. The first (principal velocities, PV-rSTD) and second (principal accelerations, PA-rSTD) time-derivatives characterized the rate-dependent sensory information associated with and the neuromuscular control of the postural movements, respectively. Children without gymnastic experience showed a different postural coordinative structure and different sensory-motor control characteristics. They used less ankle movements in the anterior-posterior direction but increased ankle movements in medio-lateral direction, presented larger hip and trunk velocities, and exhibited more hip actions. Gymnastic experience during childhood seemed to benefit the development of proprioceptive reweighting processes in children, leading to a more mature form of coordinating and controlling posture similarly to adults.

Orthopaedic patients underestimate their body weight too: a cross-sectional study.

INTRODUCTION: The relation between a large body mass and comorbidity, certain types of cancers and musculoskeletal disorders has been extensively documented. However, a high proportion of overweight patients appears unaware of the medical risks of their condition and frequently underestimates their body weight. This observation is prevalent across numerous medical specialties and settings. METHODS: This study analysed the misperception of obesity status in a cohort of 1137 patients attending an orthopaedic clinic by means of self-completed questionnaires and objective biometrics. RESULTS: Patients displayed a poor estimation of the self-body mass index (34.6%), especially among larger individuals, with 45.15% of pre-obese and 21.17% of obese patients previously attempting weight-loss. A direct association between low educational achievement and obesity rates was observed in orthopaedic patients. DISCUSSION: Obesity is a well-known contributor to many conditions, including musculoskeletal diseases. Despite this association, many obese patients consider their body mass as normal. Misperception of self-body weight has been documented in many medical specialities, and this study confirms the same scenario in orthopaedic patients. CONCLUSION: The association between self-image distortion and obesity observed in this study may assist in the evaluation and management of obesity cases in orthopaedic clinics.

Enhancing Children's Motor Memory Retention Through Acute Intense Exercise: Effects of Different Exercise Durations.

Physical exercise has been proposed as a viable means to stimulate motor learning. Exercise characteristics, including intensity and duration, may play a role in modulating the exercise effect on motor learning. While some evidence exists regarding the benefits of intense and relatively long exercise, little is known about the effect of short exercise bouts on motor learning, especially in children. This study aimed to assess the effect of long versus short intense exercise bouts on the adaptation and consolidation of a rotational visuomotor adaptation task. The participants were 71 healthy children from two sites divided into three groups: long exercise bout (LONG), short exercise bout (SHORT), and no exercise (CON). Children performed a rotated (clockwise 60° rotation) motor task on four different occasions: an adaptation set and 1 h, 24 h, and 7 days delayed retention sets. Exercise bouts were performed prior to the adaptation set. Results showed a group effect during motor adaptation [F(2,68) = 3.160; p = 0.049; η p 2 = 0.087], but no statistical differences were found between groups. Regarding retention tests, both exercise groups (LONG and SHORT) showed superior retention compared to CON group [F(2,68) = 7.102; p = 0.002; η p 2 = 0.175]. No differences were found between exercise groups, indicating similar benefits for the two exercise interventions. Overall, whether the exercise duration was long or short, exercise improved motor memory retention as an estimate of memory consolidation process. The use of short exercise bouts may be suitable to improve children's motor memory consolidation in environments where time constraints exist.

Amber in prehistoric Iberia: New data and a review.

Provenancing exotic raw materials and reconstructing the nature and routes of exchange is a major concern of prehistoric archaeology. Amber has long been recognised as a key commodity of prehistoric exchange networks in Europe. However, most science-based studies so far have been localised and based on few samples, hence making it difficult to observe broad geographic and chronological trends. This paper concentrates on the nature, distribution and circulation of amber in prehistoric Iberia. We present new standardised FTIR analyses of 22 archaeological and geological samples from a large number of contexts across Iberia, as well as a wide scale review of all the legacy data available. On the basis of a considerable body of data, we can confirm the use of local amber resources in the Northern area of the Iberian Peninsula from the Palaeolithic to the Bronze Age; we push back the arrival of Sicilian amber to at least the 4th Millennium BC, and we trace the appearance of Baltic amber since the last quarter of the 2nd Millennium BC, progressively replacing Sicilian simetite. Integrating these data with other bodies of archaeological information, we suggest that the arrival of Baltic amber was part of broader Mediterranean exchange networks, and not necessarily the result of direct trade with the North. From a methodological perspective, thanks to the analyses carried out on both the vitreous core and the weathered surfaces of objects made of Sicilian simetite, we define the characteristic FTIR bands that allow the identification of Sicilian amber even in highly deteriorated archaeological samples.

sEMG Analysis During Landing in Children With Autism Spectrum Disorder: A Pilot Study.

PURPOSE: The aim was to explore the timing and duration of muscle activation during a landing task in children with autism spectrum disorder (ASD), and compare their responses to those of children who are developing typically (TD). METHODS: Six children (ages 3-4.5 years), half with ASD, hung from a vertical bar, landed, and reacted to a light cue that signaled the child to run to the right or left or to stay in place. Electromyography and kinematics were recorded and compared between groups. RESULTS: Children with ASD had more and longer bursts of muscle activation during preimpact. In contrast, children TD displayed more and longer burst of muscle activation during impact. CONCLUSION: The results suggest that children with ASD have a less developed landing strategy compared with their peers TD. Further investigation into the neuromuscular components in children with ASD will guide future interventions for this population.

Age and gymnastic experience effects on sensory reweighting processes during quiet stand.

BACKGROUND: The relative contribution of sensory inputs to control balance while standing is dynamically adjusted. These sensory reweighting processes could be impacted by age and sport expertise capabilities, especially when the sport emphasizes equilibrium like artistic gymnastics. RESEARCH QUESTION: The aim of this study was to explore the sensory reweighting processes to adjust standing posture in children and adults with different gymnastic expertise (gymnasts, G, and non-gymnast, NG). METHODS: All participants were asked to stand quietly on a force plate in two visual conditions (eyes open, EO, and eyes closed, EC). Within a trial, proprioception was altered with two vibrators strapped at the Achilles tendon level. The center of pressure (COP) displacements in the anterior-posterior and medio-lateral directions were calculated and normalized by the base of support. The effect of vibration application was characterized by the COP speed, maximal posterior displacement and the time when it occurred. The effect of vibration removal was depicted by the time between the motor switched off and the achievement of balance values similar to baseline and the COP speed and movement units performed during this time. RESULTS: G children presented shorter posterior displacement during vibrations, needed less time to recover initial balance, and produced less movements units than NG children. In general, adults and EO showed better reweighting responses than children and EC, respectively. SIGNIFICANCE: These results suggest that age could have a positive effect on reweighting processes and that gymnastic experience may benefit the development of proprioceptive reweighting processes in children but not in adults.

The quadriceps active ratio: a dynamic MRI-based assessment of patellar height.

INTRODUCTION: Patella alta (PA) is one of the primary correctable risk factors for patellofemoral instability (PFI). Both an accurate diagnosis of PA and a clinically relevant target for correction are necessary for optimal treatment. An ideal test for PA should relate the position of the patella to the femur rather than tibia, should do so with the quadriceps contracted and the patellar tendon under tension and should have good sensitivity and specificity. None of the currently used radiographic tests PA meet these criteria, most of which are based on the position of the patella relative to the tibia with diagnostic cutoffs based on 2 standard deviations from the mean rather than optimal sensitivity and specificity. The authors describe the quadriceps active ratio (Q+R), an MRI-based assessment of PA based on patellofemoral contact under quadriceps activated with a cutoff based on optimal sensitivity a specificity for PFI. MATERIAL-METHODS: Ninety-four participants investigated for knee pain or instability with a clinically indicated MRI were recruited. Routine MRI sequences were obtained, with the addition of a quadriceps contracted sagittal T1-weighted sequence. Participants presenting with PFI were identified. Those with trochlear dysplasia were identified and excluded from analysis so that patellar height could be assessed against PFI without being confounded by trochlear dysplasia. Q+R and patellotrochlear index (PTI) were calculated from the remaining 78 scans by 3 consultant orthopaedic surgeons at three time points. In 54 of these cases, a lateral radiograph was available from which the Insall-Salvati, modified Insall-Salvati, Caton-Deschamps and Blackburn-Peel ratios were also calculated. Intra- and inter-observer reliability was assessed for the Q+R. A cutoff value for the Q+R based on optimal sensitivity and specificity for the diagnosis of PFI was calculated from receiver-operator characteristic (ROC) curves and compared to the PTI. The cutoff for the Q+R was compared for sensitivity and specificity for the diagnosis of PFI against the radiographic ratios. RESULTS: The Q+R had satisfactory or better ICC values across time points and surgeons. The Q+R was superior to the PTI on area under curve ROC analysis (0.76 vs 0.74). A cutoff value of 0.12 for the Q+R gave sensitivity of 79% and specificity of 55% for the diagnosis of PFI. The radiographic indices were generally insensitive for this diagnosis of PFI with sensitivities ranging from 0-66%. CONCLUSION: The Q+R is a reliable diagnostic test for patellar height assessment, showing good intra- and inter-rater consistency, and greater diagnostic accuracy than the PTI. A Q+R value of 0.12 is a good test for clinically significant PA. Of the radiographic indices, the Insall-Salvati ratio had the best diagnostic accuracy.

Adaptation and Retention of a Perceptual-Motor Task in Children: Effects of a Single Bout of Intense Endurance Exercise.

We assessed the effect of an acute intense exercise bout on the adaptation and consolidation of a visuomotor adaptation task in children. We also sought to assess if exercise and learning task presentation order could affect task consolidation. Thirty-three children were randomly assigned to one of three groups: (a) exercise before the learning task, (b) exercise after the learning task, and (c) only learning task. Baseline performance was assessed by practicing the learning task in a 0° rotation condition. Afterward, a 60° rotation-adaptation set was applied followed by three rotated retention sets after 1 hr, 24 hr, and 7 days. For the exercise groups, exercise was presented before or after the motor adaptation. Results showed no group differences during the motor adaptation while exercise seemed to enhance motor consolidation. Greater consolidation enhancement was found in participants who exercised before the learning task. Our data support the importance of exercise to improve motor-memory consolidation in children.

Timing, duration, and severity of iron deficiency in early development and motor outcomes at 9 months.

BACKGROUND/OBJECTIVES: Poorer motor development is reported in infants with iron deficiency (ID). The role of timing, duration and severity is unclear. We assessed relations between ID timing, duration, and severity and gross motor scores, neurological integrity, and motor behavior quality at 9 months. SUBJECTS/METHODS: Iron status was determined at birth and 9 months in otherwise healthy term Chinese infants. The 9-month motor evaluation included the Peabody Developmental Motor Scale (PDMS-2), Infant Neurological International Battery (INFANIB), and motor quality factor. Motor outcomes were analyzed by ID timing (fetal-neonatal, infancy), duration, and severity. For severity, we also considered maternal iron status. RESULTS: The data were available for 1194 infants. Iron status was classified as fetal-neonatal and infancy ID (n = 253), fetal-neonatal ID (n = 256), infancy ID (n = 288), and not ID (n = 397). Compared with not ID, infants with fetal-neonatal or infancy ID had lower locomotion scores (effect size ds = 0.19, 0.18) and those with ID in both periods (longer duration) had lower locomotion and overall PDMS-2 gross motor scores (ds = 0.20, 0.18); ID groups did not differ. More severe ID in late pregnancy was associated with lower INFANIB Vestibular function (p = 0.01), and total score (p = 0.03). More severe ID in infancy was associated with lower scores for locomotion (p = 0.03), overall gross motor (p = 0.05). CONCLUSIONS: Fetal-neonatal and/or infancy ID was associated with lower overall gross motor development and locomotion test scores at 9 months. Associations with ID severity varied by ID timing: more severe ID in late pregnancy, poorer neurological integrity; more severe ID in infancy, poorer gross motor development.

A novel approach in the treatment of acute whiplash syndrome: Ultrasound-guided needle percutaneous electrolysis. A randomized controlled trial.

INTRODUCTION: Whiplash associated disorders are currently a common musculoskeletal problem. Besides the high incidence in western countries, the costs derived from prolonged treatment and medicolegal compensation, make this entity a challenging problem for clinicians and insurance companies. To date, no conservative treatment has shown clear superiority in the management of acute cases. HYPOTHESIS: Percutaneous needle electrolysis (PNE) is an effective approach for the treatment of Quebec type II acute whiplash syndrome (AWS). PNE consists in the application of brief galvanic currents into a damaged structure, producing a local controlled inflammatory response, with subsequent tissular healing enhancement. MATERIALS AND METHODS: One hundred AWS patients were randomized into: (a) standard physiotherapy intervention for AWS; (b) a standardized PNE protocol for AWS. Both groups were assessed for treatment outcome at the 5th week mark. RESULTS: Both groups showed a statistically significant improvement according to the Northwick Park Neck Questionnaire, visual analogic scale and pressure pain threshold. The improvement was similar in both groups, except for the pain pressure threshold, with a 56.6% reduction vs. 44.4% reduction in favour of the PNE group (P=0.035). In addition, the physio group consumed a mean treatment time of 20hours, while the PNE intervention averaged less than 1 hour in total. DISCUSSION: PNE can be considered as an effective treatment option for AWS. Importantly, the technique is highly cost-effective, with limited equipment required and a notable treatment time reduction, compared to more comprehensive physiotherapy protocols. TYPE OF STUDY: Randomized controlled trial. LEVEL OF PROOF: 1b.

Comminuted Patella Fracture in Elderly Patients: A Systematic Review and Case Report.

OBJECTIVES: To review comminuted patella fracture in the elderly patients and examine the surgical options to avoid complications such as fixation failure and poor functional outcome. To provide an example of mesh augmentation in comminuted patella fracture in the elderly patients. DATA SOURCES: A literature review was conducted by the authors independently using Ovid, Medline, Cochrane, PubMed, and Clinical Key in English. We aimed to review data on patients older than 65 with comminuted patella fracture. Search conducted between July and December 2015. STUDY SELECTION: Search terms included patella fracture, elderly, and fixation failure. Abstracts were included if they were a case report, cohort series, or randomized control trial. Further inclusion criteria were that they were available in full text and included patient age(s), operative details, follow-up, and outcome discussion. DATA EXTRACTION: Each study was assessed according to its level of evidence, number of patients, age of patients, fracture patterns described, complications of treatment, and results summarized. DATA SYNTHESIS: Paucity of data and heterogeneity of studies limited statistical analysis. Data are presented as a review table with the key points summarized. CONCLUSION: In patella fracture, age >65 years and comminuted fracture pattern are predictors of increased fixation failure and postoperative stiffness, warranting special consideration. There is a trend toward improved functional outcomes when augmented fixation using mesh or plates is used in this group. Further level 1 studies are required to compare and validate new treatment options and compared them to standard surgical technique of tension band wire construct.