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In recent years, the trend in orthopedic and trauma surgery has shifted towards earlier mobilization with reduced weightbearing restrictions to enhance patient recovery. Tibial-shaft-spiral-fractures pose a challenge for early mobilization. This study examines the use of additive cerclages, which allow for immediate full-weightbearing, and compares it to the standard-of-care (SOC) treatment with partial-weightbearing. The primary aim was to evaluate mobility, return-to-daily-activities, and safety outcomes. This prospective multicenter study included 36 patients with tibial-shaft-spiral-fractures. Group1 ( n  = 20) received an additive cerclage and was permitted immediate full weightbearing-as-tolerated, while Group2 ( n  = 16) followed SOC with 20 kg partial weightbearing for 6 weeks. Gait analysis was performed at 1,3,6, and 12-weeks, as well as 6-months post-surgery, using the loadsol ® force-measuring device. Patient-reported outcomes, including pain levels, quality of life (EQ-5D), and return to daily activities, were assessed at these intervals. The results showed that immediate weightbearing as tolerated led to significantly faster mobilization. By week-3, 35% (7 of 20) of patients in Group1 were walking unassisted compared to 6.25% (1 of 16) in Group 2 ( p  = 0.04). By week 6, 75% (15 of 20) of patients in Group1 were walking without crutches, compared to 31.25% (5 of 16) in Group2 ( p  = 0.002). Gait speed and mobility were significantly improved in the cerclage group throughout the early postoperative period, with quality of life scores also higher during the early postoperative phase (gait speed week 3 2.57 ± 0.49 km/h vs. 2.16 ± 0.70 km/h, p  = 0.032; EQ-5D week 1 3.59 ± 0.85 vs. 3.05 ± 0.56, p  = 0.017). No significant differences in complications were observed between the groups. The use of additive cerclages for tibial-shaft-spiral-fractures is a safe and effective method that allows for immediate full-weightbearing, resulting in earlier mobilization and improved short-term quality of life. Trail registration number: DRKS00035464 ( www.drks.de ), Date of registration: 17/12/2024.

This randomized clinical trial evaluated the impact of immediate weight-bearing as tolerated on spatiotemporal gait parameters and fall risk in patients undergoing postoperative rehabilitation for tibial plateau fractures. A total of 106 patients who had undergone open reduction and internal fixation (ORIF) for Schatzker I-IV tibial plateau fractures were recruited, with 39 meeting the inclusion criteria and 10 lost to follow-up. Patients were randomly assigned to a non-weight-bearing group (NWB), following a 6-week non-weight-bearing rehabilitation protocol, or a weight-bearing group (WB), allowed immediate weight-bearing. Both groups received the same therapeutic exercise program. Gait parameters were assessed three months post-surgery, including step length, stride length, single stance time, double stance time, step time, stride time, velocity, cadence, stride width, and gait and balance scores from Tinetti Performance Oriented Mobility Assessment (POMA). Of the 29 patients who completed the study, significant differences in favor of the WB group were observed for affected limb step length (p = 0.010), sound limb step length (p = 0.013), stride length (p = 0.010), affected single limb stance time (p = 0.001), sound single limb stance time (p = 0.007), velocity (p = 0.021), and POMA scores for balance (p = 0.021) and gait (p = 0.002). Immediate weight-bearing as tolerated after ORIF for Schatzker I-IV tibial plateau fractures resulted in improved spatiotemporal gait parameters and reduced fall risk.

Does low intensity pulsed ultrasound (LIPUS) accelerate recovery in adults and children who have experienced bone fractures or osteotomy (cutting of a bone)? An expert panel rapidly produced these recommendations based on a linked systematic review triggered by a large multicentre randomised trial in adults with tibial fracture.

Objective To determine whether low intensity pulsed ultrasound (LIPUS), compared with sham treatment, accelerates functional recovery and radiographic healing in patients with operatively managed tibial fractures.Design A concealed, randomized, blinded, sham controlled clinical trial with a parallel group design of 501 patients, enrolled between October 2008 and September 2012, and followed for one year.Setting 43 North American academic trauma centers.Participants Skeletally mature men or women with an open or closed tibial fracture amenable to intramedullary nail fixation. Exclusions comprised pilon fractures, tibial shaft fractures that extended into the joint and required reduction, pathological fractures, bilateral tibial fractures, segmental fractures, spiral fractures >7.5 cm in length, concomitant injuries that were likely to impair function for at least as long as the patient’s tibial fracture, and tibial fractures that showed <25% cortical contact and >1 cm gap after surgical fixation. 3105 consecutive patients who underwent intramedullary nailing for tibial fracture were assessed, 599 were eligible and 501 provided informed consent and were enrolled.Interventions Patients were allocated centrally to self administer daily LIPUS (n=250) or use a sham device (n=251) until their tibial fracture showed radiographic healing or until one year after intramedullary fixation.Main outcome measures Primary registry specified outcome was time to radiographic healing within one year of fixation; secondary outcome was rate of non-union. Additional protocol specified outcomes included short form-36 (SF-36) physical component summary (PCS) scores, return to work, return to household activities, return to ≥80% of function before injury, return to leisure activities, time to full weight bearing, scores on the health utilities index (mark 3), and adverse events related to the device.Results SF-36 PCS data were acquired from 481/501 (96%) patients, for whom we had 2303/2886 (80%) observations, and radiographic healing data were acquired from 482/501 (96%) patients, of whom 82 were censored. Results showed no impact on SF-36 PCS scores between LIPUS and control groups (mean difference 0.55, 95% confidence interval −0.75 to 1.84; P=0.41) or for the interaction between time and treatment (P=0.30); minimal important difference is 3-5 points) or in other functional measures. There was also no difference in time to radiographic healing (hazard ratio 1.07, 95% confidence interval 0.86 to 1.34; P=0.55). There were no differences in safety outcomes between treatment groups. Patient compliance was moderate; 73% of patients administered ≥50% of all recommended treatments.Conclusions Postoperative use of LIPUS after tibial fracture fixation does not accelerate radiographic healing and fails to improve functional recovery.Study registration ClinicalTrialGov Identifier: NCT00667849

Purpose To compare the clinical, radiological outcomes, economic and technical differences for ORIF by cancellous screw fixation versus ARIF by double-tunnel suture fixation for displaced tibial-side PCL avulsion fractures. Methods Forty patients with displaced tibial-sided PCL avulsions were operated upon after randomizing them into two groups (20 patients each in the open and arthroscopic group) and followed up prospectively. Assessment included duration of surgery, cost involved, pre- and post-operative functional scores, radiological assessment of union, and posterior laxity using stress radiography and complications. Results The mean follow-up period was 33 months (27–42) (open group) and 30 months (26–44) (arthroscopic group). The duration of surgery was significantly larger in the arthroscopic group (47.8 ± 17.9 min) as compared to the open group (33.4 ± 10.1 min). The costs involved were significantly higher in the arthroscopic group ( p − 0.01). At final follow-up, knee function in the form of IKDC (International Knee Documentation Committee) evaluation (89.9 ± 4.8-open and 89.3 ± 5.9-arthroscopic) and Lysholm scores (94.2 ± 4.1-open and 94.6 ± 4.1-arthroscopic) had improved significantly with the difference (n.s.) between the two groups. The mean posterior tibial displacement was 5.7 ± 1.8 mm in the open group and 6.3 ± 3.1 mm in the arthroscopic group which was (n.s.). There were two non-unions and one popliteal artery injury in the arthroscopic group. Conclusion Both ARIF and ORIF for PCL avulsion fractures yield good clinical and radiological outcomes. However, ORIF was better than ARIF in terms of cost, duration of surgery, and complications like non-union and iatrogenic vascular injury. Level of evidence II.

Purpose To investigate the effects of adding immediate weight-bearing to tolerance into a post-operative rehabilitation program for surgically treated Tibial Plateau (TP) fractures on clinical and radiological outcomes. Methods A randomized control trial. 106 Patients were recruited following open reduction internal fixation (ORIF) TP fracture, with 54 patients meeting the criteria for inclusion. Patients were assigned randomly into one of two groups: (1) the traditional group (TG) and (2) the weight-bearing group (WG). The TG was given the non-weight-bearing (NWB) rehabilitation protocol for six weeks. The WG was allowed immediate weight-bearing, and the same therapeutic exercise program was given to both groups. The dependent variables, including clinical and radiological measurements, were recorded six weeks, three months, and six months after the surgery. Results A total of 45 patients (11 women and 34 men), with a mean age of 43  ±  14 years, completed the study. There were significant differences between groups in favor of the WG at 6-months for the total clinical Rasmussen score ( p  =.002) as well as for the pain ( p  =.005), walking capacity ( p  =.002), and knee ROM ( p  =.047). We found neither difference between groups regarding radiological CT- Scan and X-ray measures nor Rasmussen’s radiological scores ( p  =.854). Fracture type (Schatzker I-IV) did not affect any radiological measures between the groups. Four of 45 patients had intra-articular collapse, three in TG and one in WG ( p  =.571). Conclusion Immediate weight-bearing as tolerated after ORIF of TP fractures (Schatzker I-IV) resulted in better clinical outcomes with no significant differences in the radiological measures.

The aim of this study was to compare the clinical outcomes, biomechanical performance, and cost-effectiveness of finite element planning (FEP) with those of traditional (Trad) methods in the treatment of complex tibial plateau fractures in middle-aged and elderly patients to ultimately optimize treatment protocols, improve surgical efficiency, and reduce the economic burden on patients. Sixteen patients with complex tibial plateau fractures were randomly divided into FEP and Trad groups, with eight patients in each group. The FEP group underwent preoperative finite element analysis for personalized surgical planning and dual-plate fixation; the Trad group participated in traditional preoperative discussions and underwent a multi-plate fixation. Perioperative and postoperative indicators were collected from both groups, and the stress distribution and displacement under different internal fixation modes were evaluated using finite element analysis. Additionally, a cost-effectiveness analysis was conducted to compare the total costs of internal fixation and hospitalization. The surgical times were significantly shorter in the FEP group than in the Trad group (170.00 ± 59.52 vs. 240.00 ± 59.04 min, p  = 0.033), and patients in the Trad group had shorter times to ambulation (12.88 ± 0.99 vs. 14.25 ± 1.49 days, p  = 0.047). There were no significant differences between the groups in terms of postoperative orthopaedic scores, mobility indices, fracture healing times, or radiological indicators. Biomechanical analysis revealed that the multiplate fixation mode provided a more uniform stress distribution, but this difference was not statistically significant. In the FEP group, the total costs of internal fixation (4772.25 ± 217.31 vs. 8991.88 ± 2811.25 yuan, p  = 0.004) and hospitalization (34796.75 ± 9749.19 vs. 65405.14 ± 28684.80 yuan, p  = 0.013) were significantly lower. While ensuring clinical effectiveness, FEP demonstrated greater cost-effectiveness by shortening the surgery time and reducing internal fixation costs. Although the multiplate fixation mode was biomechanically superior to the dual-plate mode, it did not result in significant clinical advantages and was more costly. FEP improves the economic efficiency of treatment for complex tibial plateau fractures in middle-aged and elderly patients and is recommended. This study has certain limitations, such as a small sample size and a short follow-up period. Thus, larger-scale studies with longer-term follow-up data are needed to further validate these findings and explore whether all patient populations can benefit from these practices or if the benefits are limited to specific groups, such as elderly patients or those with certain types of fractures.

Introduction Preoperative planning is a critical step in the success of any complex surgery. The pur-pose of this study is to evaluate the advantage of VR glasses in surgical planning of complex tibial plateau fractures compared to CT planning. Materials and methods Five orthopedic surgeons performed preoperative planning for 30 fractures using either conventional CT slices or VR visualization with a VR headset. Planning was performed in a randomized order with a 3-month interval between planning sessions. A standardized questionnaire assessed planned operative time, planning time, fracture classification and understanding, and surgeons’ subjective confidence in surgical planning. Results The mean planned operative time of 156 (SD 47) minutes was significantly lower ( p  < 0.001) in the VR group than in the CT group (172 min; SD 44). The mean planning time in the VR group was 3.48 min (SD 2.4), 17% longer than in the CT group (2.98 min, SD 1.9; p  = 0.027). Relevant parameters influencing planning time were surgeon experience (-0.61 min) and estimated complexity of fracture treatment (+ 0.65 min). Conclusion The use of virtual reality for surgical planning of complex tibial plateau fractures resulted in significantly shorter planned operative time, while planning time was longer compared to CT planning. After VR planning, more surgeons felt (very) well prepared for surgery.

Purpose. The aim of this study was to assess the feasibility and effectiveness of the three-dimensional (3D) printing technology in the treatment of Pilon fractures. Methods. 100 patients with Pilon fractures from March 2013 to December 2016 were enrolled in our study. They were divided randomly into 3D printing group (n=50) and conventional group (n=50). The 3D models were used to simulate the surgery and carry out the surgery according to plan in 3D printing group. Operation time, blood loss, fluoroscopy times, fracture union time, and fracture reduction as well as functional outcomes including VAS and AOFAS score and complications were recorded. To examine the feasibility of this approach, we invited surgeons and patients to complete questionnaires. Results. 3D printing group showed significantly shorter operation time, less blood loss volume and fluoroscopy times, higher rate of anatomic reduction and rate of excellent and good outcome than conventional group (P<0.001, P<0.001, P<0.001, P=0.040, and P=0.029, resp.). However, no significant difference was observed in complications between the two groups (P=0.510). Furthermore, the questionnaire suggested that both surgeons and patients got high scores of overall satisfaction with the use of 3D printing models. Conclusion. Our study indicated that the use of 3D printing technology to treat Pilon fractures in clinical practice is feasible.

Purpose Freehand distal interlocking of intramedullary nails remains a challenging task. Recently, a new training device for digitally enhanced hands-on surgical training (DEHST) was introduced, potentially improving surgical skills needed for distal interlocking. Aim To evaluate whether training with DEHST enhances the performance of novices (first-year residents without surgical experience in freehand distal nail interlocking). Methods Twenty novices were randomly assigned to two groups and performed distal interlocking of a tibia nail in mock operation under operation-room-like conditions. Participants in Group 1 were trained with DEHST (five distal interlocking attempts, 1 h of training), while those in Group 2 did not receive training. Time, number of X-rays shots, hole roundness in the X-rays projection and hit rates were compared between the groups. Results Time to complete the task [414.7 s (range 290–615)] and X-rays exposure [17.8 µGcm 2 (range 9.8–26.4)] were significantly lower in Group 1 compared to Group 2 [623.4 s (range 339–1215), p  = 0.041 and 32.6 µGcm 2 (range 16.1–55.3), p  = 0.003]. Hole projections were significantly rounder in Group 1 [95.0% (range 91.1–98.0) vs. 80.8% (range 70.1–88.9), p  < 0.001]. In Group 1, 90% of the participants achieved successful completion of the task in contrast to a 60% success rate in Group 2. This difference was not statistically significant ( p  = 0.121). Conclusions In a mock-operational setting, training with DEHST significantly enhanced the performance of novices without surgical experience in distal interlocking of intramedullary nails and hence carries potential to improve safety and efficacy of this important and demanding surgical task to steepen the learning curve without endangering patients. Level of evidence II.