Aims. The primary aim of this study is to compare mobility status of patients receiving oral oxycodone with those receiving subcutaneous alfentanil as analgesic methods prior to mobilization to help physiotherapy compliance after hip fracture surgery. The secondary aims are to assess postoperative pain, health-related quality of life, in-hospital length of stay, total use of analgesia over postoperative days 1 and 2 (POD 1 and POD 2), complication rates within 30 days, and 30-day mortality rates. Methods. A single-centre, prospective cohort study of 64 patients will be undertaken. Patients undergoing surgery for femoral neck fractures at the study centre will be recruited. Patients with a hip fracture meeting the inclusion/exclusion criteria will be enrolled on admission. Patients who have been administered oral oxycodone will be compared to those prescribed alfentanil for pain prior to mobilization with physiotherapists on POD 1 and POD 2. Which drug a patient receives is reliant of the prescriptions given by the medical team, and in current practice this varies at approximately 50:50. Mobilization will be defined as the ability to stand on and weightbear both feet with or without assistance. Results. Visual analogue scale pain scores, mobility status, and total analgesia use will be assessed on POD 1 and POD 2. EuroQol five-dimension health questionnaire scores, complication rates, and mortality rates will be assessed up to 30 days following surgery (POD 1, 2, 7, and 30). Conclusion. This study will help to build a wider protocol aiming to improve early mobilization after hip fracture surgery. The results of this study will provide pain scores and mobility status which will either support use of subcutaneous alfentanil as the standard analgesic modality prior to physiotherapy sessions, or highlight its limitations compared to the standard oral oxycodone. Secondary outcomes will also help to assess if early mobilization improves outcomes compared to delayed mobilization. Cite this article: Bone Jt Open 2025;6(1):53–61

Objective. To evaluate early mobilization with the ‘STRONG regime’ is safe after lateral ankle ligament repair with suture tape augmentation. Background. The ESSKA-AFAS ankle instability group presented in 2016 evidence-based guidelines for rehabilitation and return to activity after lateral ankle ligament repair. Early mobilization is considered an important element of postoperative rehabilitation. Patients have to be immobilized for approximately six weeks to protect the delicate repair. Lateral ankle ligament repair with suture tape augmentation results in greater strength compared with standard repairs and early mobilization proved to be successful in small sample size studies. Augmented surgery technique is getting increasingly popular. However, it is unknown which rehabilitation regimes are used. It is essential to establish a clear evidence-based guideline for rehabilitation after surgery. Methods. A systematic literature search was performed to obtain the best evidence research regarding this surgery. In cooperation between the orthopaedic- and physical therapy department a post-operative rehabilitation protocol with early mobilization was established. This STRONG protocol (figure 1) is based on milestones and three stages. Results. In February 2016 the first patients were selected for the early mobilization regime. In total 102 patients with a lateral ankle ligament repair were treated with the STRONG protocol. No re-ruptures were observed with a follow up of a year. In a subgroup of athletes hop tests showed a symmetry index of 100,5% for triple hop, 98,6 for side hop and 103,6 for figure of 8 hop. First return to sport was achieved between 9–12 weeks, with full return to competition after a mean of 4 months. Conclusions. An early postoperative mobilization regime based on supervised exercises seems to be a safe intervention after a lateral ankle ligament reconstruction. Clinical implications. Augmented ankle ligament surgery with early mobilization could be an important advancement in treating patients with chronic ankle injuries. For any figures or tables, please contact authors directly

Total shoulder arthroplasty (TSA) and Reverse Total shoulder arthroplasty (RSA) are two of the most performed shoulder operations today. Traditionally postoperative rehabilitation included a period of immobilisation, protecting the joint and allowing time for soft tissue healing. This immobilisation period may significantly impact a patient's quality of life (Qol)and ability to perform activities of daily living (ADL's). This period of immobilisation could be safely avoided, accelerating return to function and improving postoperative QoL.

This systematic review examines the safety of early mobilisation compared to immobilisation after shoulder arthroplasty focusing on outcomes at one year.

The management of femoral bone loss is challenging during revision hip arthroplasty. In patients with Paprosky grade IIIB and IV defects, obtaining fixation and rotational stability using traditional surgical constructs is difficult. The use of a custom-made internal proximal femoral replacement prostheses has been proposed as a solution in patients, with severe femoral bone stock loss. However, there is a paucity in the literature on their use and long-term outcomes. We report on the clinical and radiological results of our cohort.

We retrospectively reviewed all patients who underwent internal proximal femoral replacement for revision hip arthroplasty between April 1996 and April 2019. All patients had at least 2 years of follow-up time.

160 patients underwent limb salvage at our institution using internal proximal femoral replacement. The mean follow-up was 79.7 months (S.D 41.3). Indications for revision included periprosthetic fractures, aseptic loosening, and deep infection. The mean Oxford hip score increased from 13.8 (0–22) to 31.5 (18–43) (paired t-test, p < 0.001). Kaplan-Meier prosthesis survival analysis with revision as the endpoint was 87% at 5 years. None required revision of the femoral stem. There were four dislocations (5%) and there was failure to eradicate the deep infection in four.

This technique allows instant distal fixation, allowing for early mobilisation. Long-term clinical and radiological outcomes are encouraging and the complication rates are acceptable for this patient group.

Introduction

Hindfoot intramedullary nail fixation (HFN) or fibula pro-tibial screw fixation (PTS) are surgical options for ankle fractures in patients with multiple co-morbidities; we compared their outcomes.

Prompt mobilisation after the Fracture neck of femur surgery is one of the important key performance index (‘KPI caterpillar charts’ 2021) affecting the overall functional outcome and mortality. Better control of peri-operative blood pressure and minimal alteration of renal profile as a result of surgery and anaesthesia may have an implication on early post-operative mobilisation.

Aim was to evaluate perioperative blood pressure measurements (duration of fall of systolic BP below the critical level of 90mmHg) and effect on the post-operative renal profile with the newer short acting spinal anaesthetic agent (prilocaine and chlorprocaine) used alongside the commonly used regional nerve block. 20 patients were randomly selected who were given the newer short acting spinal anaesthetic agent along with a regional nerve block between May 2019 and February 2020. Anaesthetic charts were reviewed from all patients for data collection. The assessment criteria for perioperative hypotension: Duration of systolic blood pressure less than 90 mm of Hg and change of pre and post operative renal functions.

Only one patient had a significant drop in systolic BP less than 90mmHg (25 minutes). 3 other patients had a momentary fall of systolic BP of less than 5 minutes. None of the above patients had mortality and had negligible change in pre and post op renal function. Only one patient in this cohort had elevation of post-operative creatinine levels but did not have any mortality. Only 1 patient died on day 3 post operatively who had multiple comorbidities and was under evaluation for GI cancer. Even in this patient the peri-operative blood pressure was well maintained (never below 90mmHg systolic) and post-operative renal function was also shown to have improved (309 pre-operatively to 150 post-operatively) in this patient.

The use of short-acting spinal anaesthesia has shown to be associated with a better control of blood pressure and end organ perfusion, less adverse effects on renal function leading to early mobilisation and a more favourable patient outcome with reduced mortality, earlier mobilisation, shorter hospital stay and earlier discharge in this elderly patient cohort.

Appropriate surgical management of hip fractures has major clinical and economic consequences. Recently IMN use has increased compared to SHS constructs, despite no clear evidence demonstrating superiority of outcome. We therefore set out to provide further evidence about the clinical and economic implications of implant choice when considering hip fracture fixation strategies.

A retrospective cohort study using Scottish hip fracture audit (SHFA) data was performed for the period 2016–2022. Patients ≥50 with a hip fracture and treated with IMN or SHS constructs at Scottish Hospitals were included. Comparative analyses, including adjustment for confounders, were performed utilising Multivariable logistic regression for dichotomous outcomes and Mann-Whitney-U tests for non-parametric data. A sub-group analysis was also performed focusing on AO-A1/A2 configurations which utilised additional regional data. Cost differences in Length of Stay (LOS) were calculated using defined costs from the NHS Scotland Costs book. In all analyses p<0.05 denoted significance.

13638 records were included (72% female). 9867 received a SHS (72%).

No significant differences were identified in 30 or 60-day survival (Odds Ratio [OR] 1.05, 95%CI 0.90–1.23; p=0.532), (OR 1.10, 95%CI 0.97–1.24; p=0.138) between SHS and IMN's.

There was however a significantly lower early mobilisation rate with IMN vs SHS (OR 0.64, 95%CI 0.59–0.70; p<0.001), and lower likelihood of discharge to domicile by day-30 post-admission (OR 0.77, 95%CI 0.71–0.84; p<0.001). Acute and overall, LOS were significantly lower for SHS vs IMN (11 vs 12 days and 20 vs 24 days respectively; p<0.001). Findings were similar across a sub-group analysis of 559 AO A1/A2 fracture configurations.

Differences in LOS potentially increases costs by £1230 per-patient, irrespective of the higher costs of IMN's v SHS.

Appropriate SHS use is associated with early mobilisation, reduced LOS and likely with reduced cost of treatment. Further research exploring potential reasons for the identified differences in early mobilisation are warranted.

Introduction

The current study reports on the impact of immediate mobilization of patients treated by tissue-preserving, computer-assisted total hip arthroplasty on length of stay, disposition, and complications.

Background: It is commonly believed that early motion after joint fixation is a good thing, especially in the upper limb, but in the ankle joint this is much less clear. No previous systematic review of the evidence for this could be found in the literature.

Materials and Methods: Nine randomised Control Trials were identified which met the inclusion criteria and compared early motion of the ankle joint to immobilisation in a cast for six weeks. These varied in quality and numbers. All treated patients equally in all other respects including weight bearing. Where outcome measures were similar, some meta-analysis was possible.

Results: There is good evidence that early motion results in a quicker return to work on average (p=0.008) and results in improved range of motion at 12 weeks (dorsiflexion p= 0.001; plantarflexion p < 0.00001) compared to cast immobilisation. However it also results in an increased risk of wound infection (p=0.002). There is a suggestion that early motion results in a lower rate of deep vein thrombosis, but this is not quite significant (p=0.12). There is no evidence that it results in improved joint specific outcome scores or range of motion at 1 year.

Discussion: It is difficult to state that early motion is better or worse than cast immobilisation for every patient. The evidence suggests however that a young fit patient who needs to return to work may benefit from early motion of the ankle joint whereas an older diabetic patient with poor skin would be better treated in cast.

To systematically review the literature regarding post-surgical treatment regimens on ankle fractures, specifically whether there is a benefit to early weightbearing or early mobilization (6 weeks form surgery). The PubMed, MEDLINE and Embase databases were searched from inception to May 24, 2020. All randomized controlled trials that analyzed the effects of early weightbearing and mobilization following an ankle surgery were included. The primary outcome measure was the Olerud Molander Ankle Score (OMAS). Secondary outcomes included return to work (RTW) and complications. Logistic regression models with random intercepts were used to pool complication data by protocol clustered by study. Twelve RCT's were included, with a total of 1177 patients (41.8 ± 8.4 years). In total, 413 patients underwent early weightbearing and early mobilization (35%), 338 patients underwent early weightbearing and delayed mobilization (29%), 287 patients underwent delayed weightbearing and early mobilization (24%), and 139 patients underwent delayed weightbearing and delayed mobilization (12%). In total, 81 patients had a complication (7%), including 53 wound complications (5%), 11 deep vein thromboses (1%), and 2 failures/nonunions (0%). Early ankle mobilization resulted in statistically significant increases in OMAS scores compared to delayed mobilization (3 studies [222 patients], 12.65; 95% CI, 7.07-18.22; P < 0.00001, I2 = 49%). No significant differences were found between early and delayed weightbearing at a minimum of one-year follow-up (3 studies [377 patients], 1.91; 95% CI, −0.73-4.55, P = 0.16, I2 = 0%). Patients treated with early weightbearing and early mobilization were at higher odds of facing any complication (OR 3.6, 95%CI 1.05-12.1, p=0.041) or wound complications (OR 4.9, 95%CI 1.3-18.8, p=0.022) compared to those with delayed weightbearing and delayed mobilization. Early mobilization following surgical treatment for an ankle fracture resulted in improved ankle function scores compared to delayed mobilization regimens. There were no significant differences between early and delayed weightbearing with respect to patient reported outcomes. Patients who were treated with early mobilization and early weightbearing had an increased odds of postoperative complications

Aims. The aim of this study to compare 30-day survival and recovery of mobility between patients mobilized early (on the day of, or day after surgery for a hip fracture) and patients mobilized late (two days or more after surgery), and to determine whether the presence of dementia influences the association between the timing of mobilization, 30-day survival, and recovery. Methods. Analysis of the National Hip Fracture Database and hospital records for 126,897 patients aged ≥ 60 years who underwent surgery for a hip fracture in England and Wales between 2014 and 2016. Using logistic regression, we adjusted for covariates with a propensity score to estimate the association between the timing of mobilization, survival, and recovery of walking ability. Results. A total of 99,667 patients (79%) mobilized early. Among those mobilized early compared to those mobilized late, the weighted odds ratio of survival was 1.92 (95% confidence interval (CI) 1.80 to 2.05), of recovering outdoor ambulation was 1.25 (95% CI 1.03 to 1.51), and of recovering indoor ambulation was 1.53 (95% CI 1.32 to 1.78) by 30 days. The weighted probabilities of survival at 30 days post-admission were 95.9% (95% CI 95.7% to 96.0%) for those who mobilized early and 92.4% (95% CI 92.0% to 92.8%) for those who mobilized late. The weighted probabilities of regaining the ability to walk outdoors were 9.7% (95% CI 9.2% to 10.2%) and indoors 81.2% (95% CI 80.0% to 82.4%), for those who mobilized early, and 7.9% (95% CI 6.6% to 9.2%) and 73.8% (95% CI 71.3% to 76.2%), respectively, for those who mobilized late. Patients with dementia were less likely to mobilize early despite observed associations with survival and ambulation recovery for those with and without dementia. Conclusion. Early mobilization is associated with survival and recovery for patients (with and without dementia) after hip fracture. Early mobilization should be incorporated as a measured indicator of quality. Reasons for failure to mobilize early should also be recorded to inform quality improvement initiatives. Cite this article: Bone Joint J 2021;103-B(7):1317–1324

Aims. The evidence demonstrating the superiority of early MRI has led to increased use of MRI in clinical pathways for acute wrist trauma. The aim of this study was to describe the radiological characteristics and the inter-observer reliability of a new MRI based classification system for scaphoid injuries in a consecutive series of patients. Methods. We identified 80 consecutive patients with acute scaphoid injuries at one centre who had presented within four weeks of injury. The radiographs and MRI scans were assessed by four observers, two radiologists, and two hand surgeons, using both pre-existing classifications and a new MRI based classification tool, the Oxford Scaphoid MRI Assessment Rating Tool (OxSMART). The OxSMART was used to categorize scaphoid injuries into three grades: contusion (grade 1); unicortical fracture (grade 2); and complete bicortical fracture (grade 3). Results. In total there were 13 grade 1 injuries, 11 grade 2 injuries, and 56 grade 3 injuries in the 80 consecutive patients. The inter-observer reliability of the OxSMART was substantial (Kappa = 0.711). The inter-observer reliability of detecting an obvious fracture was moderate for radiographs (Kappa = 0.436) and MRI (Kappa = 0.543). Only 52% (29 of 56) of the grade 3 injuries were detected on plain radiographs. There were two complications of delayed union, both of which occurred in patients with grade 3 injuries, who were promptly treated with cast immobilization. There were no complications in the patients with grade 1 and 2 injuries and the majority of these patients were treated with early mobilization as pain allowed. Conclusion. This MRI based classification tool, the OxSMART, is reliable and clinically useful in managing patients with acute scaphoid injuries. Cite this article: Bone Jt Open 2022;3(11):913–920

Mechanical failure due to dislocation, fracture and acetabular wear as well as persistence of infection are the main complications associated with the use of hip spacers in the treatment of periprosthetic joint infections (PJI). We have developed a novel, custom-made spacer as part of two-stage septic hip replacement and present the two- to five-year results after reimplantation. We prospectively examined a total of 73 patients over our study period in whom our new spacer technique was used. The technique includes a dual mobility inlay and a cemented straight stem in combination with antibiotic-loaded PMMA bone cement which allows full weight bearing meanwhile the interim period. The follow-up ranged between 24 and 60 months after reimplantation as second stage of a two-stage approach. The patients were contacted as part of the follow-up using a questionnaire concerning reoperation, reinfection as well as hip function by using the Harris Hip Score. 72 patients (98,6%) could be reimplanted, one patient is still using the spacer prothesis for 45 months because of excellent functional results with a Harris Hip Score of 95, nevertheless reimplantation is planned. The reinfection rate was less than 7% after reimplantation. The dislocation rate was 5%, and in total there was an overall complication rate of less than 10%. The Harris Hip Score was significantly improved. The ENDO spacer surgical technique is a promising option in the treatment of periprosthetic joint infections (PJI) for two-stage septic exchange with a low dislocation rate and good infection control after reimplantation. In addition, it enables early mobilization with the possibility of full weight-bearing in the interval between spacer implantation and reimplantation

Total Knee Arthroplasty (TKA) improves the quality of life of osteoarthritic and rheumatoid arthritis patients, however, is associated with moderate to severe postoperative pain. There are multiple methods of managing postoperative pain that include epidural anesthesia but it prevents early mobilization and results in postoperative hypotension and spinal infection. Controlling local pain pathways through intra-articular administration of analgesics is a novel method and is inexpensive and simple. Hence, we assess the effects of postoperative epidural bupivacaine injection along with intra-articular injection in total knee replacement patients. The methodology included 100 patients undergoing TKA randomly divided into two groups, one administered with only epidural bupivacaine injection and the other with intra-articular cocktail injection. The results were measured based on a 10-point pain assessment scale, knee's range of motion (ROM), and Lysholm knee score. The VAS score was lower in the intra-articular cocktail group compared to the bupivacaine injection group until the end of 1-week post-administration (p<0.01). Among inter-group comparisons, we observed that the range of motion was significantly more in cocktail injection as compared to the bupivacaine group till the end of one week (p<0.05). Lysholm's score was significantly more in cocktail injection as compared to the bupivacaine group till the end of one week (p<0.05). Our study showed that both epidural bupivacaine injection and intra-articular injection were effective in reducing pain after TKA and have a comparable functional outcome at the end of 4 weeks follow up. However, the pain relief was faster in cases with intra-articular injection, providing the opportunity for early rehabilitation. Thus, we recommend the use of intra-articular cocktail injection for postoperative management of pain after total knee arthroplasty, which enables early rehabilitation and faster functional recovery of these patients

Abstract. INTRODUCTION. The anatomic distal femoral locking plate (DF-LCP) has simplified the management of supracondylar femoral fractures with stable knee prostheses. Osteoporosis and comminution seem manageable, but at times, the construct does not permit early mobilization. Considerable soft tissue stripping during open reduction and internal fixation (ORIF) may delay union. Biological plating offsets this disadvantage, minimizing morbidity. Materials. Thirty comminuted periprosthetic supracondylar fractures were operated from October 2010 to August 2016. Fifteen (group A) were treated with ORIF, and fifteen (group B) with closed (biological) plating using the anatomical DF-LCP. Post-operatively, standard rehabilitation protocol was followed in all, with hinged-knee-brace supported physiotherapy. Clinico-radiological follow-up was done at 3 months, 6 months, and then yearly (average duration, 30 months), and time to union, complications, failure rates and function were evaluated. Results. Average time to union was 4.5 months (range, 3–6 months) in group A, and 3.5 months (range, 2.5–5 months) in group B. Primary bone grafting was done in twelve patients (all group A). At final follow-up, all fractures had healed, and all (but two) patients were walking unsupported, with no pain or deformity, with average knee range of motion (ROM) of 90° (range, 55 to 100°). Two patients had superficial infection (group A), two had knee stiffness (group A), one had shortening of 1.5cm (group B) and one had valgus malalignment of 10 degrees (group B). Conclusion. Biological plating in comminuted supracondylar fractures about stable TKA prostheses is an excellent option, may obviate need for bone grafting, and reducing complications

We report the impact of implementing a new short-stay hip and knee arthroplasty pathway in a National Health Service (NHS) hospital. This was enacted due to existing concerns with a long length of stay (LOS) and reduced elective operating capacity each winter due to emergency bed pressures. The overnight introduction of this pathway was aimed to reduce LOS, alleviate bed pressures, minimise readmission rates and generate financial savings, all combining to facilitate full elective activity during the winter. We conducted a prospective study at a regional tertiary arthroplasty centre. The new pathway was introduced across the service overnight. It includes rigorous preoperative optimisation, specific anaesthetic protocols and uniform changes in surgical practice to allow a focus on early mobilization and discharge on the day of surgery where possible. Data collection spanned 17 months, including the initial six months post implementation of the short-stay pathway. LOS data was collected for the full period and data was compared pre- and post-implementation of the new pathway. Patient satisfaction and 30-day readmission data were also collected. There was an immediate and significant decrease in median LOS from 4 days pre-implementation to 1 day post-implementation. Patient satisfaction was high, and the 30-day readmission rate was unchanged (5.95%), with no readmissions directly related to decreased inpatient stay. Financial analyses revealed substantial cost savings due to reduced LOS and the elimination of routine post-operative blood tests, estimated at over £1.6m per year. Elective activity over winter was significantly higher (79%) than in the same time period in the previous year. An acute introduction of a carefully planned and coordinated short-stay hip and knee pathway is safe, cost-effective and popular with patients, but also contributes to increased efficiency in the delivery of elective healthcare in the context of increasing demand and financial constraints in the NHS

Background. The treatment of chronic calcaneal osteomyelitis is a challenging and increasing problem because of the high prevalence of diabetes mellitus and operative fixation of heel fractures. In 1931, Gaenslen reported treatment of hematogenous calcaneal osteomyelitis by surgical excision through a midline, sagittal plantar incision. We have refined this approach to allow successful healing and early mobilization in a modern series of complex patients with hematogenous, diabetic, and postsurgical osteomyelitis. Methods. Twenty-eight patients (mean age 54.6 years, range 20–94) with Cierny-Mader stage IIIB chronic osteomyelitis were treated with sagittal incision and calcaneal osteotomy, excision of infected bone, and wound closure. All patients received antibiotics for at least 6 weeks, and bone defects were filled with an antibiotic carrier in 20 patients. Patients were followed for a mean of 31 months (SD 25.4). Primary outcome measures were recurrence of calcaneal osteomyelitis and below-knee amputation. Secondary outcome measures included 30-day postoperative mortality and complications, duration of postoperative inpatient stay, footwear adaptions, mobility, and use of walking aids. Results. All 28 patients had failed previous medical and surgical treatment. Eighteen patients (64%) had significant comorbidities. The commonest causes of infection were diabetes ± ulceration (11 patients), fracture-related infection (4 patients), pressure ulceration, hematogenous spread, and penetrating soft tissue trauma. The overall recurrence rate of calcaneal osteomyelitis was 18% (5 patients) over the follow-up period, of which 2 patients (7%) required a below-knee amputation. Eighteen patients (64%) had a foot that comfortably fitted into a normal shoe with a custom insole. A further 6 patients (21%) required a custom-made shoe, and only 3 patients required a custom-made boot. Conclusion. Our results show that a repurposed Gaenslen calcanectomy is simple, safe, and effective in treating this difficult condition in a patient group with significant local and systemic comorbidities

Hallux valgus surgery can result in moderate to severe post-operative pain requiring the use of narcotic medication. The percutaneous distal metatarsal osteotomy is a minimally invasive approach which offers many advantages including minimal scarring, immediate weight bearing and decreased post-operative pain. The goal of this study is to determine whether the use of narcotics can be eliminated using an approach combining multimodal analgesia, ankle block anesthesia and a minimally invasive surgical approach. Following ethics board approval, a total of 160 ambulatory patients between the ages of 18-70 with BMI ≤ 40 undergoing percutaneous hallux valgus surgery are to be recruited and randomized into Narcotic-free (NF) or Standard (S) groups. To date, 72 patients have been recruited (38 NF and 34 S). The NF group received acetaminophen, naproxen, pregabalin 75mg and 100mg Ralivia (tramadol extended release) before surgery and acetaminophen, naproxen, pregabalin 150mg one dose and Ralivia 100mg BID for five days, as well as a rescue narcotic (hydromorphone, 1mg pills) after surgery. The S group received acetaminophen and naproxen prior to surgery and acetaminophen, naproxen and hydromorphone (1mg pills) post-operatively, our current standard. Visual analog scales (VAS) were used to assess pain and narcotic consumption was recorded at 6, 12, 24, 36, 48, 72 hours and seven days post-operatively. Patients wore a smart watch to record the number of daily steps and sleep hours. A two-sided t-test was used to compare the VAS scores and narcotic consumption. During the first post-operative week, the NF group consumed in total an average of 6.5 pills while the S group consumed in total an average of 16 pills and this difference was statistically significant (p-value=0.001). Importantly, 19 patients (50%) in the NF group and four patients (12%) in the S group did not consume any narcotics post-operatively. For the VAS scores at 24, 48, 72 hours and seven days the NF group's average scores were 2.17, 3.17, 2.92, 2.06 respectively and the S group's average scores were 3.97, 4.2, 3.23, 1.97. There was a statistically significant difference between the groups at 24 and 48hours (the NF group scored lower on the VAS) with a p-value of 0.0008 and 0.04 respectively, but this difference is not considered clinically significant as the minimal clinically important difference reported in the literature is a two-point differential. The NF group walked an average of 1985.75 steps/day and slept an average of 8h01 minute/night, while the S group walked an average of 1898.26 steps/day and slept an average of 8h26 minutes/night in the first post-operative week. Hallux valgus remains a common orthopedic foot problem for which surgical treatment results in moderate to severe post-operative pain. This study demonstrates that with the use of multimodal analgesia, ultrasound guided ankle blocks and a percutaneous surgical technique, narcotic requirements decreased post-operatively. The use of long-acting tramadol further decreased the need for narcotic consumption. Despite decreased use of narcotics, this combined novel approach to hallux valgus surgery allows for early mobilization and excellent pain control

Abstract. In aged trauma patients the basic prerequisite is early mobilization and full weight-bearing, as immobilization can trigger various complications such as pressure ulcers, pneumonia, urinary tract infections and others. Mortality of elderly patients increases significantly in fracture patients with partial weight-bearing compared to populations with total weight-bearing. Besides the limited physical strength in these patients, partial-weight bearing is however frequently used for the aftercare of hip fracture patients. Therefore, the present study aims to evaluate mobility of aged hip fracture patients with regards to weight-bearing and postoperative mobility. Methods. An insole mobile force sensor was used to measure the post-operative weight-bearing by assessing the compressive forces between foot and shoe. Only patients (n=15) that suffered a trochanteric fracture >75 years of age were included and compared to a study group of patients (n=18) with fractures of the lower limb <40 years of age. Patients with cognitive disorders such as delirium and other diseases limiting the realization of partial weight-bearing were excluded. Both groups were instructed to maintain partial weight bearing of the affected limb following surgery. Following five days of training by our department of physiotherapy, the patients were requested to perform a gait analysis with the insole mobile force sensor. During gait analysis the maximum load was measured (kg) and the time over which the partial load could be maintained was determined. Results. None of the aged patients in the test group could meet the partial load at all times. 73.33% of patients (11 out of 15) exceeded the specified load by more than twice (> 40 kg). In the control group, 55.56% (10 of 18) of the patients were able to meet the partial load. A further 22.22% of the young patients (4 out of 18) were able to exceed only slightly (<120%, <24 kg). It was also shown that only 11.11% (2 of 18) put more than double of the allowed weight (> 40 kg) on the affected leg in the younger group. Only one of the aged patients was able to exceed the pre-determined weight-bearing restrictions for less than 10% of the measured time. In comparison, significantly more patients in the control group (88,89%; 16 of 18; p<0,05) were able to maintain the partial load for more than 90.0% of the time of gait analysis. Conclusion. Elderly patients seem to be unable to follow partial weight-bearing restrictions as proven in the present trial. As early mobilization of geriatric trauma patients is an important element for a successful rehabilitation, the relict of postoperative partial weight-bearing in these patients should be abandoned. Thus, the surgical therapy should allow immediate full weight bearing following surgery of aged hip fracture patients

Introduction and Objective. Plating of geriatric distal femoral fractures with Locking Compression Plate Distal Femur (LCP–DF) often requires augmentation with a supplemental medial plate to achieve sufficient stability allowing early mobilization. However, medial vital structures may be impaired by supplemental medial plating using a straight plate. Therefore, a helically shaped medial plate may be used to avoid damage of these structures. Aim of the current study was to investigate the biomechanical competence of augmented LCP–DF plating using a supplemental straight versus helically shaped medial plate. Materials and Methods. Ten pairs of human cadaveric femora with poor bone quality were assigned pairwise for instrumentation using a lateral anatomical 15-hole LCP–DF combined with a medial 14-hole LCP, the latter being either straight or manually pre-contoured to a 90-degree helical shape. An unstable distal femoral fracture AO/OTA 33–A3 was simulated by means of osteotomies. All specimens were biomechanically tested under non-destructive quasi-static and destructive progressively increasing combined cyclic axial and torsional loading in internal rotation, with monitoring by means of optical motion tracking. Results. Initial axial stiffness and torsional stiffness in internal and external rotation for straight double plating (548.1 ± 134.2 N/mm, 2.69 ± 0.52 Nm/° and 2.69 ± 0.50 Nm/°) was significantly higher versus helical double plating (442.9 ± 133.7 N/mm, 2.07 ± 0.32 Nm/° and 2.16 ± 0.22 Nm/°), p≤0.04. Initial interfragmentary axial displacement and flexural rotation under 500 N static loading were significantly smaller for straight plating (0.11 ± 0.14 mm and 0.21 ± 0.10°) versus helical plating (0.31 ± 0.14 mm and 0.68 ± 0.16°), p<0.01. However, initial varus deformation under this loading remained not significantly different between the two fixation methods (straight: 0.57 ± 0.23°, helical: 0.75 ± 0.34°), p=0.08. During dynamic loading, within the course of the first 4000 cycles the movements of the distal fragment in flexion were significantly bigger for helical over straight plating (1.03 ± 0.33° versus 0.40 ± 0.20°), p<0.01. However, no significant differences were observed between the two fixation methods in terms of varus, internal rotation, axial and shear displacements at the fracture site, and number of cycles to failure. Conclusions. Augmented lateral plating of unstable distal femoral fractures with use of supplemental helically shaped medial plate was associated with more elastic bone-implant construct behavior under static and dynamic loading compared to straight double plating. Both fixation methods resulted in comparable number of cycles to failure. From a biomechanical perspective, the more elastic helical double plating may be considered as useful alternative to straight plating, potentially reducing stress risers at the distal bone-implant interface due to its ameliorated damping capacities