Is unrestricted weight bearing immediately after fixation of rotationally unstable pelvic fractures safe?

INTRODUCTION: Rotationally unstable pelvic fractures treated with surgical fixation have traditionally been treated with restricted weight bearing on the affected side for 6-8 weeks post operatively. We have been developing pelvic fixation standards to allow for unrestricted weight bearing immediately post operatively in type B rotationally unstable pelvic fractures. AIMS: To assess for safety and efficacy of allowing unrestrictive weight bearing in this cohort of patients, we have clinically and radiologically monitored outcomes up to two years post operatively. METHODS: Through retrospective review, two cohorts of patients with Tile Type B pelvic fractures were identified that were treated at the Royal Adelaide Hospital, South Australia. Patient demographics, injury classification, surgical fixation and weight bearing status post operatively was recorded. One cohort of patients was allowed to fully weight bear post operatively, whilst the other was treated with 6 weeks of restricted post op weight bearing. At clinical follow up, post-operative x-rays were assessed for loss of reduction, screw or plate breakage and reoperation. RESULTS: Between January 2018 and January 2021, 53 patients with rotationally unstable pelvic fractures that underwent surgical fixation were included in this study. One group of patents were allowed to immediately weight bear as tolerated (WBAT) post operatively (n = 28) and the other with restricted weightbearing (RWB) (n = 25). There was 1 re operation for failure of fixation in each group. Metalwork breakage was more common in the WBAT group than in the RWB group and this was seen only in APC fractures. This increase in metalwork failure was not associated with loss of reduction. CONCLUSIONS: With surgical fixation, Tile type B rotationally unstable pelvic fractures can be allowed immediate weight bearing post operatively. We found this to be safe and effective, employing surgical strategies to address both anterior and posterior injuries to allow immediate unrestricted weight bearing. Broken metalwork was more commonly seen in the WBAT group but this was not associated with loss of reduction or reoperation.

Operative management of fragility fractures of the pelvis - a systematic review.

BACKGROUND: The incidence of osteoporotic pelvic fractures in elderly patient is rising. This brings an increasing burden on health and social care systems as these injuries often lead to prolonged hospital admissions, loss of independence, morbidity and mortality. Some centres now advocate stabilisation of these injuries to reduce pain, facilitate early mobilisation, decrease hospital stay and restore independence. A systematic review of the literature was planned to establish the evidence for this intervention. METHODS: A systematic review was performed according to PRISMA guidelines. A clinical librarian performed a search of the following databases: NHS Evidence, TRIP, the Cochrane Database of Systematic Reviews, MEDLINE and EMBASE. Seventeen eligible studies were identified with 766 patients. RESULTS: The quality of evidence was poor with no good quality randomised trials. The majority of injuries were minimally displaced. Posterior ring injuries were most often stabilised with percutaneous screws which were sometimes augmented with void filler. A number of techniques were described for stabilisation of the anterior ring although fixation of the anterior ring was frequently not performed. There was consistent evidence from the included studies that operative intervention significantly improved pain. Complications were minimal but there were increased failure rates when a single unaugmented sacroiliac joint screw was used. The limited availability of non-operative comparators made it difficult to draw firm conclusions about the efficacy of surgical over non-surgical management in these patients. CONCLUSIONS: Operative management of fragility fractures of the pelvis should be considered for patients failing a brief period of non-operative management, however prospective randomised trials need to be performed to provide improved evidence for this intervention. Surgeons should consider which fixation techniques for fragility fractures of the pelvis are robust enough to allow immediate weightbearing, whilst minimising operative morbidity and post-operative complications. PROSPERO Systematic Review ID: CRD42020171237.

Current concepts: managing acetabular fractures in the elderly population.

The aim of this review is to summarise the current concepts in the management of acetabular fractures in the elderly population. A literature review of the evidence regarding the management of elderly acetabular fractures was performed utilising PubMed and Ovid. The predominant causes and fracture patterns of acetabular fractures are changing as populations age. Consequently, the operative management has had to change also. Judet and LeTournel did not offer operative treatment to any patients older than sixty. However, in the present time, according to the German Pelvic Registry, over half the patients aged sixty or over, sustaining acetabular fractures underwent operative fixation. We find that the increasing age of the population raises particular challenges for the operating surgeon. Postoperative rehabilitation should be focused on early mobilisation. More research needs to be focussed on standardised treatment protocols and long-term outcomes for this cohort of patients.

Tibia plateau fracture mapping and its influence on fracture fixation.

BACKGROUND: Tibial plateau fracture classifications are based on anteroposterior radiographs. Precontoured locking plates are commonly used to treat such fractures. The aims of this study are to: (1) describe tibial plateau fracture anatomy in the axial plane and (2) assess whether current plating systems allow screws to be placed suitably. MATERIALS AND METHODS: A graphical tibial plateau template was developed. One hundred twenty-five tibial plateau fractures (four bilateral) were reviewed (80 men, 41 women; average age 45.5 years, range 21-77.7 years). The axial computed tomography (CT) slice 0.3-0.5 mm below the medial articular surface was reviewed in all cases. Fracture lines were drawn on the template. Four lateral locking plates were placed against a cadaveric adult tibia. Based on the projected screw directions, suitable fracture patterns were identified. Fractures were considered "suitable" if the screws passed 90 ± 22° to the fracture line. RESULTS: Two hundred sixty-one different fracture lines were identified. One hundred thirty-four fractures involved the lateral plateau; 96 were suitable for lateral plating. Ninety fractures involved the medial plateau, 82 were treatable using the various plate positions on medial-posterior aspect of the medial plateau. Thirty-seven fractures were bicondylar; 20 were treatable with a posteromedial plate. CONCLUSIONS: Tibial plateau fractures follow consistent patterns, with most lateral and medial plateau fracture lines being in the sagittal plane, although there is greater variation medially. Positioning of modern locking plates will deal effectively with 72 % of all lateral plateau fractures and 91 % of medial plateau fractures. LEVEL OF EVIDENCE: Level 3.

POWIFF- Prospective study of wrist internal fixation of fracture: A protocol for a single centre, superiority, randomised controlled trial to study the efficacy of the VRP (2.0) distal radius plate (Austofix) versus the VA-LCP (Depuy-Synthes) for distal radius fractures.

BACKGROUND: Distal radial fractures are one of the most common orthopaedic cases that present to the A&E department. Surgical intervention is warranted in displaced intraarticular fractures and fractures with more than the recommended angulation or shortening, and is most commonly treated with volarly placed fixed angle locking plates. The aim of this study is to determine and compare the efficacy of two different plates for surgical treatment of distal radius fractures. The VRP 2.0 is a new plate produced by the Austofix company and this system will be compared against the VA-LP (Variable angle-locking plate) produced by Depuy-Synthes which has been used as the standard treatment device. METHODS AND DESIGN: Patients between the ages of 18 and 80 presenting to the Royal Adelaide Hospital with isolated closed distal radial fractures will be invited to participate in this study. A total of 200 patients are required to provide 90% statistical power at a 5% alpha level to detect a difference of 11.5 points on the PRWE (Patient rated Wrist evaluation) score. The primary outcome measure will be the PRWE score while the secondary outcome measures will include the DASH score, EQ5D score, clinical range of movements, grip strength as well as patient perceived return of function at the wrist and time to resumption to work. These will be measured at 6 weeks, 3 months and 12 months. Radiographic indices including the radial tilt, length, volar inclination and plate prominence will also be measured. Complications will be recorded up to 12 months. Post hoc comparisons will be done using paired t tests. An intention to treat and a per protocol analysis will be done to compare the 2 groups. DISCUSSION: Distal radial fractures are increasingly being treated by internal fixation using volar locking plates. However, there is no prospective study to date comparing one plate against another in terms of outcome and complications. This study could provide more information about the best way to treat these injuries surgically. TRIAL REGISTRATION: The trial is registered with the Australia New Zealand Clinical Trials Registry (ANZCTR). Trial registration date-17/11/2016. Trial registration number- ACTRN12616001590459 .

Outcomes and early revision rate after medial unicompartmental knee arthroplasty: prospective results from a non-designer single surgeon.

BACKGROUND: This prospective study evaluates outcomes and reoperation rates for unicompartmental knee arthroplasty (UKA) from a single non-designer surgeon using relatively extended criteria of degenerative changes of grade 2 or above in either or both non-operated compartments. METHODS: 187 consecutive medial mobile bearing UKA implants were included after history, clinical assessment and radiological evaluation. 91 patients had extended clinical outcomes. Post-operative assessment included functional scoring with the Oxford Knee Score (OKS) and radiographic review. Survivorship curves were constructed using the life-table method, with 95% confidence intervals calculated using Rothman's equation. Separate endpoints were examined: revision for any reason and revision for confirmed loosening. RESULTS: The mean follow-up was 3.5 years. The pre-operative OKS improved from a mean of 21.2 to 38.9 (Mann-Whitney U Test, p = < 0.001). Twelve Patients required further operations including 9 revisions. No patients developed deep infection and no surviving implants were loose radiographically. Survivorship at 7 years with endpoints of re-operation, revision and aseptic loosening at surgery or radiographically was 88.4% (95% CI 79.6-93.7), 93.1% (95% CI 85.5-96.9) and 97.3% (95% CI 91.2-99.2) respectively. The presence of pre-operative mild contralateral tibiofemoral or any extent of patellofemoral joint degeneration was of no consequence. DISCUSSION: The indications for UKA are being expanded to include patients with greater deformity, more advanced disease in the patellofemoral joint and even certain features in the lateral compartment indicative of an anteromedial pattern of osteoarthritis (OA). However, much of the supporting literature remains available only from designer centres. This study represents a group of patients with what we believe to be wider indications, along with decisions to treat made on clinical grounds and radiographs alone. CONCLUSION: This study shows comparable clinical outcomes of UKA for extended indications from a high volume, high-usage non-designer unit.

The impact of helipad designation on meeting the best practice tariff for fractured neck of femur cases in a major trauma centre.

Hip fractures represent a significant burden to the NHS: the cost for all UK hip fractures is approximately £2 billion and in 2013, 64 838 people were admitted to hospital with a fractured neck of femur (FNOF). In April 2010 St George's NHS Hospital was designated one of four Major Trauma Centres (MTC) in London. Following MTC designation, in April 2014 St George's Hospital opened a helipad. This study aimed to assess the impact of the helipad designation on the Trust's ability to meet the Best Practice Tariff (BPT) criteria for FNOF patients. Two samples were analysed: 'pre-helipad' (from October 2013 to March 2014) during which 125 patients presented with FNOF, and 'post-helipad' (from April 2014 to September 2014) during which 122 patients presented with FNOF. The percentage of cases receiving surgery within 36 h, receiving joint care of a consultant geriatrician and a consultant orthopaedic surgeon, and receiving assessment by a geriatrician in the perioperative period were found not to have been negatively impacted by the helipad. However, completion of routine recommended assessments including admission using the agreed assessment protocol (96.6% vs. 50%, p < 0.05) and completion of two Abbreviated Mental Test (AMT) scores (74.7% vs. 58%, p = 0.007) were found to have been compromised.

Advantages in Using Cemented Polished Tapered Stems When Performing Total Hip Arthroplasty in Very Young Patients.

BACKGROUND: The risk of revision following primary total hip arthroplasty (THA) is increased in young patients who undergo THA for pathologies other than primary osteoarthritis. We report the results of primary THA performed with cemented polished stems in patients aged 40 years and younger for pathologies other than primary osteoarthritis. METHODS: We investigated 52 patients (65 hips) who underwent primary THA for secondary osteoarthritis with a cemented tapered polished stem between 1990 and 2007. Clinical and radiographic outcomes, available in 46 patients (57 hips), included the Harris Hip Scores, Societe Internationale de Chirurgie Orthopedique et de Traumatologie activity, patient satisfaction, stem survival and reoperations, and assessment of prosthesis-cement-bone radiolucencies, osteolysis, and femoral bone deficiencies. RESULTS: Median patient age was 34 years (16-40) and follow-up was 14 years (mean 13, range 5-22). Stem survival to the endpoint revision for loosening was 100% and to the endpoint revision for any reason, excluding infection was 88% (95% confidence interval 78-98) at 16 years. No stem was revised for aseptic loosening. Nine stems were revised for other reasons. Radiographically, one stem was definitely loose at 16 years. The median patient Harris pain score improved from marked pain to no pain at latest follow-up. Patient activity level improved, albeit minimally, for 8 years after surgery. At latest follow-up, 98% of the patients remained satisfied with their surgery. CONCLUSION: Primary THA with a cemented polished stem shows excellent results in young patients with pathology other than primary osteoarthritis. In addition, the stem design facilitates cement within cement exchange and therefore preservation of proximal femoral bone stock at revision surgery.

Managing acetabular fractures in the elderly with fixation and primary arthroplasty: aiming for early weightbearing.

BACKGROUND: Osteoporotic acetabular fractures in the elderly are becoming more common. Regardless of treatment, most patients are managed with a period of protected weightbearing, even if a THA has been performed. We have tried to treat these patients analogously to geriatric femoral neck fractures in a way that allows immediate full weightbearing. QUESTIONS/PURPOSES: We determined return to mobility, length of hospital stay (LOS), radiographic outcomes, and complications in a series of elderly osteoporotic patients treated for acetabular fractures with early fracture fixation and simultaneous THA, allowing full weightbearing immediately postoperatively. METHODS: Since 2009, one surgeon (MR) used a consistent approach for fracture fixation and THA with immediate weightbearing in all patients older than 65 years with acetabular fractures who were fit for surgery and whose injuries were deemed osteoporotic fractures (low-energy mechanisms) meeting particular radiographic criteria (significant marginal impaction or femoral head damage). Twenty-four patients met these criteria and were reviewed at a mean of 24 months (range, 8-38 months). Mean age was 77 years (range, 63-90 years), and eight patients were women. The surgical technique included plate stabilization of both acetabular columns plus simultaneous THA using a tantalum socket and a cemented femoral stem. Clinical and note reviews were conducted to ascertain return to mobility, LOS, and postoperative complications. Component migration and fracture healing were assessed on plain radiographs. RESULTS: All patients mobilized with full weightbearing by Day 7 postoperatively. Only one patient remained dependent on a frame to mobilize at discharge. At 6 weeks, two patients already required no walking aids. At 6 months, patients were using a single stick at home at most, and all patients had managed stairs. Mean LOS was 18 days (range, 10-36 days). Radiographically, no component migration was seen in any patient. Seventeen of 24 fractures (71%) healed radiographically by 12 weeks, and all healed by 6 months. We recorded one superficial wound infection, one symptomatic deep venous thrombosis, and one in-hospital death from myocardial infarction. CONCLUSIONS: Selected older patients with acetabular fractures may be managed using immediate weightbearing after fracture fixation and THA. However, this surgery is complex and requires a mixed skill set. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

The absence of reporting standards and a lack of objective, performance-based outcomes following intramedullary nailing of tibial shaft fractures: findings from a scoping review into 179 articles.

PURPOSE: This scoping review was conducted to summarise the outcome tools reported in the assessment of tibial shaft fractures treated with intramedullary (IM) nailing, with a key focus on knee pain and function, and performance-based outcomes. METHODS: PubMed and Embase databases were searched on May 31, 2023. All study designs and populations were included, including ex vivo studies without fracture. Studies with only open or intra-articular fractures, or other fracture fixation, were excluded. Reported outcome tools and pertinent study characteristics were extracted and summarised. RESULTS: Of 488 articles identified, 179 met the inclusion criteria. For in vivo studies (n = 152), there were 13,705 fractures; the IM nailing approach not described for 30% of these. There were 133 unique patient outcomes, with a binary assessment of knee pain (29% of studies) and Lysholm score (21%) most common. Only 10/152 (7%) in vivo studies included an objective, performance-based measure of knee function. Fracture union was most frequent (52%) of 81 different clinical outcomes. For ex vivo studies (n = 29), there were 408 tibias included, with nail insertion location most prevalent (66% of studies) of 34 reported outcomes. CONCLUSION: The heterogeneity of outcome tools reported limits comparison between studies and the most commonly reported patient outcomes may not be the most appropriate. Future studies should report the IM nailing approach and consider capturing both patient-reported and performance-based outcomes to help inform surgical decision making.

Hip biomechanics in early recovery following fixation of intertrochanteric fractures: Results from a randomised controlled trial.

Single and dual integrated screw femoral nails are both commonly used to treat intertrochanteric fractures. This study investigated if using single or dual integrated screw femoral nails result in different post-operative hip joint loading. In the presence of differences, we investigated potential contributing factors. Patients were randomised for treatment via single screw (Stryker, Gamma3) or dual-integrated screw nail (Smith and Nephew, Intertan). Pre-injury mobility levels were collected at enrolment. Hip radiographs and gait data were collected at six weeks (Gamma: 16; Intertan: 15) and six months (Gamma: 14; Intertan: 13) follow-up. The resultant hip joint reaction forces and abductor muscle forces were estimated using electromyography-assisted neuromusculoskeletal modelling during level walking gait. Our primary analysis focused on the resultant hip joint reaction force and abductor muscle forces. We compared between groups, across stance phase of walking gait, using statistical parametric mapping. At six weeks, the Intertan group showed a short (∼5% of stance phase) but substantial (33 % [0.3 × body weight] greater magnitude) resultant hip joint reaction force when compared to the Gamma group (P = 0.022). Higher gluteus medius forces (P = 0.009) were demonstrated in the Intertan group at six weeks. Harris Hip Scores followed the trend seen for the biomechanical outcomes with superior scores for the Intertan group at six weeks postoperative (P = 0.044). The use of dual-integrated screw femoral nails over single screw devices may allow for hip biomechanics more closely resembling normal hip function at earlier post-operative timepoints, but these appear to resolve by six months postoperative.

Gait biomechanics after proximal femoral nailing of intertrochanteric fractures.

Proximal femur fractures in the elderly are associated with significant loss of independence, mobility, and quality of life. This prospective study aimed to: (1) investigate gait biomechanics in intertrochanteric fracture (ITF) patients (A1 and A2 AO/OTA) managed via femoral nailing at 6 weeks and 6 months postoperative and how these compared with similarly aged elderly controls; and (2) investigate whether femoral offset shortening (FOS) and lateral lag screw protrusion (LSP) were associated with changes in gait biomechanics at postoperative time points. Hip radiographs and gait data were collected for 34 patients at 6 weeks and 6 months postoperatively. Gait data were also collected from similarly aged controls. FOS and LSP were measured from radiographs. Joint angles, external moments, and powers were calculated for the hip, knee, and ankle and compared between time points in ITF patients and healthy controls using statistical parametric mapping. The relationship between radiographic measures with gait speed, step length, peak hip abduction, and maximum hip abduction moment was assessed using a Pearson correlation. External hip adduction moments and hip power generation improved in the first 6 months postoperative, but differed significantly from healthy controls during single limb stance. LSP showed a moderate correlation with maximum hip abduction moment at 6 weeks postoperative (r = -0.469, p = 0.048). These results provide new detail on functional outcomes after ITF and potential mechanisms that functional deficiencies may stem from. Lag screw prominence may be an important factor in maintaining functional independence and minimizing the risk of secondary falls after ITF in the elderly.

Retention of kinematic patterns during a 6-minute walk test in people with knee osteoarthritis.

BACKGROUND: Knee osteoarthritis (OA) is a chronic condition affecting the entire joint and surrounding tissue, resulting in pain, stiffness and impaired movement. Recent studies have suggested the use of physical performance tests, such as the six-minute walk test (6MWT) to assess joint function for those with knee OA. This study assessed lower limb sagittal plane joint angles during a 6MWT for people with mild-moderate knee OA. METHODS: Thirty-one participants (18 male, 13 female; 62.9 ± 8.4 years) with knee OA were recruited. Gait data were collected in a single session during which participants completed a 6MWT around a 20 m course. Sagittal plane joint angles for the hip, knee and ankle were calculated during the first and last minute of the 6MWT. Statistical parametric mapping (SPM) was used to investigate changes in kinematic traces over the gait cycle. RESULTS: Mean joint angles for the hip and knee showed no significant differences between the first and last minute of the 6MWT. Ankle joint kinematic traces indicated there to be a decrease in plantarflexion approaching toe-off in the last minute of the test - a 1.5° reduction from the first minute. No significant differences were calculated for walking speed or joint range of motion. DISCUSSION: The lack of significant change in joint kinematic parameters and walking speed suggests the relative fatigue and pain burden to the participant over the duration of the 6-minute period is insufficient to elicit any mechanical changes to walking gait.

Outcomes analysis of anterior and lateral approach for open repair of hip abductor tendons.

BACKGROUND: Gluteal tendons tears are increasingly being recognised as a cause of recalcitrant trochanteric pain, but there is a paucity of robust studies analysing the type of tears, results and predictors of outcome. METHODS: Patients with gluteal tendon tears resistant to conservative treatment who underwent isolated open repair (IR) or total hip arthroplasty and concomitant repair (THA+repair) with a minimum 1-year follow-up were retrospectively assessed separately. Type of tear, surgical approach, and fixation methods were registered. Complications and postoperative outcomes were analysed: visual analogue scale (VAS) of pain, VAS satisfaction, and activity level. Univariate regressions and multivariable models were developed. RESULTS: 90 cases were included: 62 cases underwent IR and 28 cases THA+repair, with an average follow-up of 3.9 years and 2.6 years, respectively. 13 complications were found (n = 5 IR, n = 8 THA+repair), including 9 re-operations (n = 4 IR, n = 5 THA+repair). Mean VAS pain score was 3.02 (SD 2.74) for the IR and 2.32 (SD 2.43) for THA+repair group. Mean VAS satisfaction was 7.09 (SD 3.07) and 7.68 (SD 2.71) for the IR and THA+repair group, respectively. In the IR group 61.4% returned to all pre-injury activities, whereas in the THA+repair group 79% did. Full-thickness tears had higher VAS pain scores (p = 0.0175), and there was trend (p > 0.05) towards higher complications, re-tears and lower VAS satisfaction in this type of tears in both groups. No statistically significant differences were found in outcomes when comparing THA+repair through direct anterior (DAA) with lateral approach (LA). CONCLUSIONS: Isolated gluteal tendon repair or THA+repairs seem to be safe procedures with high levels of satisfaction at short- to mid-term follow-up. The presence of a full-thickness tear is a predictor of inferior outcomes.

The effect of weight compared to BMI on patient reported outcomes at long term follow up of primary total hip arthroplasty.

Introduction: Obesity has been linked to the development of osteoarthritis meaning that a large portion of arthroplasty patients are overweight or obese. Whilst the short-term complications associated with obesity are well described there is a paucity of evidence on the effect of weight compared to BMI for long term functional outcomes of total hip replacements (THR). The aim of this study was to investigate the influence of BMI and weight on long-term patient reported outcome measures following primary THR. Methods: 846 patients who underwent primary THR at the Royal Adelaide Hospital between 2000 and 2009 had a pre-operative height and weight recorded. Patient reported outcome measures (PROMs) were completed at 1, 5 and greater than 10 years follow-up. Categorical comparison of PROMs was performed for patients in weight categories of 0-65 kg, 65-80 kg, 80-95 kg, 95-110 kg and >110 kg; and BMI categories as per the WHO Classifications. Results: There was no difference in absolute or change in PROMs for any weight category. BMI did not have an effect on the change in (HHS), however there was a statistically significant decrease in absolute (HHS) values at 1 and 5 years with increasing obesity. 65 patients underwent revision within the first ten years. Conclusion: The results from this study confirm for the first time that there was no impact of weight or BMI on the change in long-term PROMs of THR. There remains a need for larger registry studies to investigate the effect of weight and BMI on long-term patient outcomes and revision rate.

Thrombo-prophylaxis in pelvic and acetabular trauma patients: a UK consensus?

AIMS: The incidence of deep vein thrombosis, non-fatal pulmonary embolism and fatal pulmonary embolism may be as high as 61%, 10% and 2%, respectively, in patients with pelvic and acetabular injuries. A survey of the pelvic and acetabular units across the United Kingdom was performed to ascertain the thrombo-prophylaxis policy for these patients. In particular, questions were asked about different regimes on post-operative patients, conservatively managed patients and those simply discussed over the telephone. We enquired about their known rates of DVT and PE and their methods of data collection. METHODS: Postal questionnaires were sent to 22 pelvic and acetabular trauma centres around the United Kingdom. RESULTS: Replies from 18 units were received in which a total of 837 operations are performed per year. Forty-five percent of pelvic and acetabular units do not routinely prescribe chemical prophylaxis for post-operative patients and 56% do not prescribe prophylaxis for conservatively managed patients. The policy of the remaining units showed no consistency in duration or agent. Fifty-three percent of units use a database to collect information related to the numbers of patients operated up on. Forty-seven percent have no defined method for collecting DVT and PE numbers. For this reason, reported rates of proximal DVT, non-fatal PE and fatal PE were below that expected at 2.5%, 0.8% and 0.1%, respectively. CONCLUSIONS: Despite high rates of thrombo-embolic complications in patients with pelvic and acetabular injuries there is no UK consensus on prescribing prophylaxis.

An instrumented walker in three-dimensional gait analysis: Improving musculoskeletal estimates in the lower limb mobility impaired.

BACKGROUND: In three-dimensional (3D) gait analysis of individuals requiring a walking frame (walker), acquisition of artefact-free motion and force data is challenging. Without inclusion of handle-reaction forces alongside ground reaction forces, external forces used in musculoskeletal modelling are incomplete. This may increase dynamic inconsistencies between the model and measured motions and forces, thus, uncertainties in estimates of musculoskeletal load. RESEARCH QUESTION: To develop an instrumented walker and evaluate the effects of including handle-reaction forces on residual forces during musculoskeletal modelling. METHODS: An instrumented walker measuring handle-reaction forces synchronously with motion capture and ground reaction force data was developed. 3D gait analysis was conducted in ten elderly participants recovering from a proximal femur fracture and requiring a walker for ambulation. Joint kinetics and residual forces were calculated between two external load conditions: (1) external loads applied using only force platforms; or (2) external loads applied using force platforms and walker handle-reaction forces. RESULTS: Including handle-reaction forces reduced residual forces and improved estimates of musculoskeletal loads of the torso (P = <0.001). SIGNIFICANCE: A wide instrumented walker measuring handle-reaction forces allows for the gait analysis of individuals requiring a walker and improves reliability of musculoskeletal dynamics.

Visualising knee loading patterns during kneeling and the development of a laboratory-based adaptation of the Aberdeen Weight-Bearing Test (Knee).

BACKGROUND: Information regarding the loading of key anatomical structures of the knee during kneeling would enhance existing functional tests, yet current visualisation methods are limited and require further development. AIMS: (1) Develop a knee loading visualisation technique to investigate loading patterns of the knee during kneeling; and (2) determine the utility of the technique in combination with vertical ground reaction forces and centre of pressure data in the lab-based Aberdeen Weight-Bearing Test (Knee) by assessing their reliability. METHODS: Fourteen healthy participants conducted kneeling tasks with and without knee pads across two testing sessions. Eight force-sensitive resistors were affixed to the right knee throughout different kneeling tasks: upright kneeling, and reaching forward, back, left, and right. A photo of the force-sensitive resistor configuration was used to generate participant-specific heat maps of knee loading. Two in-ground force platforms were used to measure vertical ground reaction forces and centre of pressure. RESULTS: The inferior patella tendon showed the highest proportion of activation during both bare and knee pad kneeling for all kneeling tasks. Knee pads reduced the repeatability of knee loading patterns. Force-sensitive resistor activation and vertical ground reaction force components of the lab-based Aberdeen Weight-Bearing Test (Knee) were shown to be reliable, whereas the centre of pressure data was unreliable. CONCLUSION: We have developed a lab-based technique for visualising knee loading using force-sensitive resistors. The combination of force-sensitive resistor activation and vertical ground reaction force data provides valuable insights into both the magnitude and locations of applied loads throughout kneeling.

Investigating and defining outcomes of suprapatellar versus infrapatellar intramedullary nailing of tibial shaft fractures: a protocol for a pilot randomised controlled trial.

BACKGROUND: Anterior knee pain is often reported following intramedullary nailing of tibial shaft fractures. The aetiology remains unclear, but the surgical approach may play an important role. To date, no biomechanically validated method exists to assess patient outcomes specific to anterior knee pain in this cohort. The central aims of this study are to (1) evaluate the feasibility of a full-scale randomised controlled trial (RCT) investigating the influence of surgical approach on intramedullary nailing of tibial shaft fractures (suprapatellar versus infrapatellar nailing), (2) explore differences in clinical outcomes between the approaches, and (3) explore the development of a biomechanically validated methodology for assessing post-operative anterior knee pain and knee function specific to intramedullary nailing of tibial shaft fractures. METHODS: This pilot study will follow a prospective randomised controlled design at the Royal Adelaide Hospital and The Queen Elizabeth Hospital (South Australia). This study aims to recruit 60 patients between 18 and 60 years old who will be randomly assigned to either the suprapatellar or infrapatellar approach following a decision for intramedullary surgical fixation by the treating surgeon. All nails in this study will be Stryker T2 Alpha nails. Patients will undergo standard radiograph, magnetic resonance imaging, and clinical assessments in-line with their standard operative care, and complete a number of patient-reported and performance-based outcome measures. Performance-based outcome measures will be assessed utilising three-dimensional motion capture techniques. Follow-up time points are 3, 6, 12, and 18 months. Feasibility outcomes include ability to meet enrolment and retention metrics, compliance with all questionnaires and assessment procedures, and the occurrence of any adverse events. The primary clinical outcome is the incidence of anterior knee pain at 12 months after surgery. DISCUSSION: This study will establish the feasibility and inform the design of a large-scale RCT. Evaluation of all clinical data and patient outcomes will lead to the development of a new tool for assessing patient outcomes in this cohort. Limitations of the study include an unpredictable enrolment rate and loss to follow-up, small sample size, and the unknown ability of three-dimensional motion analysis to pick up the effects of anterior knee pain after tibial nailing. TRIAL REGISTRATION: This trial was prospectively registered on the 7 February 2020 on ANZCTR, ACTRN12620000109909 .

Reoperation rates after proximal femur fracture fixation with single and dual screw femoral nails: a systematic review and meta-analysis.

Purpose: The purpose of this study was to investigate differences in aseptic reoperation rates between single or dual lag screw femoral nails,in the treatment of intertrochanteric fractures (ITF) in elderly patients. Methods: Electronic databases were searched for RCTs and prospective cohort studies treating elderly ITF patients with a single or dual screw femoral nails. Data for aseptic reoperation rates between single screw, dual separated screw and dual integrated screw devices were pooled using a random-effects meta-analysis with 95% CIs. Pooled proportions were compared using a N-1 chi-squared test. Complications contributing to aseptic reoperation rates were extracted, and the contribution of cut-out and periprosthetic fracture as a proportion of reoperations was analysed using a negative binomial regression model. Results: Forty-two (n = 42) studies were evaluated, including 2795 patients treated with a single screw device, 1309 patients treated with a dual separated screw device and 303 patients treated with a dual integrated screw device. There was no significant difference in aseptic reoperation rates between single and dual lag screw femoral nails of both separated and integrated lag screw designs. Moreover, complications of cut-out and periprosthetic fracture as a proportion of reoperations did not differ significantly between devices. Conclusion: The current evidence showed that aseptic reoperation rates were not significantly different between single and dual screw nails of a separated lag screw design. For dual integrated screw devices, due to insufficient evidence available, further high quality RCTs are required to allow for decisive comparisons with these newer devices.