Few things are more disheartening to an orthopaedic surgeon than taking a patient back into the operating suite to treat a failure of fixation. In part, that’s because we realize that the chances of obtaining stable fixation, especially in elderly patients with poor bone density, are diminished with the second attempt. We are additionally cognizant of the risks (again, most significant in the elderly) to cardiopulmonary function with a second procedure shortly after the initial one.
These concerns have led us historically to instruct patients to limit weight bearing for 4 to 6 weeks after hip-fracture surgery. On the other hand, we have seen evidence in cohort studies to suggest that instructing elderly patients with proximal femur fractures to bear weight “as tolerated” after surgery is safe and does not increase the risk of fixation failure.
In the June 6, 2018 issue of The Journal, Kammerlander et al. demonstrate that 16 cognitively unimpaired elderly patients with a proximal femur fracture were unable to limit postoperative weight bearing to ≤20 kg on their surgically treated limb—despite 5 training sessions with a physiotherapist focused on how to do so. In fact, during gait analysis, 69% of these elderly patients exceeded the specified load by more than twofold, as measured with insole force sensors. This inability to restrict weight bearing is probably related to balance and lower-extremity strength issues in older patients, but it may be challenging for people of any age to estimate and regulate how much weight they are placing on an injured lower limb.
With this and other recent evidence, we should instruct most elderly patients with these injuries to bear weight as comfort allows and prescribe correspondingly active physical therapy. As surgeons, we should focus our efforts on the quality and precision of fracture reduction and placement of surgical implants. This will lead to higher patient, family, and physical-therapist satisfaction and pave the way for a more active postoperative rehabilitation period and better longer-term outcomes.
Marc Swiontkowski, MD
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Chad Krueger, MD, in response to a recent study in the Annals of Internal Medicine.
Few disease processes are as prevalent within the United States as hip and knee osteoarthritis (OA). While OA is commonly thought to be a disease of older age, the reality is that over half of all individuals with knee arthritis are younger than 65. While some of those individuals will eventually go on to have a knee arthroplasty, before that, most OA patients try various other treatments in an effort to decrease pain and increase function. Medications such as NSAIDs and others are certainly a part of these treatment efforts, but nonpharmacologic treatments are also widely recommended.
However, as Bennell et al. clearly state in their Annals article, patients face multiple barriers to the implementation of these nonoperative, nonpharmacologic modalities, including cost and transportation to relevant clinical specialists. The authors used these barriers as the rationale for a randomized trial in which an intervention group of knee OA patients received Internet-based educational material, online pain-coping skills training, and videoconferencing with a physiotherapist who provided individualized exercises for each patient. A control group received only the educational material.
At 3 and 9 months, both groups showed improvements in pain and function, but the intervention group had significantly greater improvements than the control group. More importantly, the people in the intervention group largely adhered to all online programs on their own and were very satisfied with the prescribed treatments, especially the video-based physiotherapy component.
Internet-based health interventions are certainly not new. However, my suspicion is that 20 years from now we will look back and wonder why we did not use them more often. They are self-directed, cost-effective, reproducible, and available to any of the 87% of Americans over the age of 50 who, according to the Pew Research Center, use the Internet. These online interventions require no driving to an office, and patients can easily track their own progress by seeing how many modules they have completed.
While there are certainly limitations to the findings from Benell et al., as an accompanying editorial by Lisa Mandl, MD points out, the study serves as a very strong proof of concept that should be expanded upon. Dr. Mandl herself proclaims that “these results are encouraging and show that ‘telemedicine’ is clearly ready for prime time.”
With the number of ways we “stay connected” always increasing, it seems important for orthopaedists to learn how to use these technologies to benefit our patients. Doing so may require some adjustments, but the ultimate goal of improving the quality of life for our patients warrants whatever creativity and open-mindedness might be necessary.
Chad Krueger, MD is a military orthopaedic surgeon at Womack Army Medical Center in Fort Bragg, North Carolina.
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of key findings from Level I and II studies cited in the November 18, 2015 Specialty Update on orthopaedic rehabilitation:
- A prospective comparison of patients who received either skilled physical therapy (PT) or a standardized home exercise program after total knee arthroplasty (TKA) found that range of motion and functional outcome were similar in the two groups after two years, but the home program was nearly half the cost of PT.1
- A randomized trial of 198 patients who underwent TKA compared telerehabilitation with face-to-face rehab. After two months, WOMAC and KOOS scores and functional and range-of-motion tests were all noninferior for telerehabilitation.
- A randomized trial of community-dwelling elderly patients who had undergone hip fracture surgery found that an individualized home-based rehab program produced superior functional outcomes, balance, and mobility recovery when compared with a standard, non-structured home exercise program.2
- A claims-data study of 4733 people who underwent hip or knee replacement found a 29% decrease in postoperative acute service utilization among those who had preoperative PT.
- A randomized trial comparing active transcutaneous nerve stimulation (TENS), placebo TENS, and standard care during rehab for TKA found that adding either active or placebo TENS to standard care significantly reduced movement pain in the immediate postoperative period.3
- A randomized study found that in-hospital sling-based range-of-motion therapy had a clinically beneficial effect up to three months after TKA surgery in terms of passive knee flexion range of motion, compared with an in-hospital continuous passive motion protocol.4
- A randomized trial comparing weight-bearing and non-weight-bearing for nonoperative treatment of Achilles tendon ruptures found no significant between-group differences in the Total Rupture Score or heel-rise strength.
- A systematic review and meta-analysis comprising 402 patients who had undergone surgical Achilles tendon repair found that postoperative early weight-bearing and early ankle motion exercises were associated with a lower minor complication rate and greater functional recovery when compared with conventional immobilization.5
- A randomized trial comparing 12 weeks of individualized resistance training to physiotherapy without resistance training in adolescents and young adults with bilateral spastic cerebral palsy found that neither group demonstrated improvements in performance of daily physical activity.6
- A randomized trial of three methods of weight-bearing training (verbal instruction, bathroom scale training, and haptic biofeedback) found that haptic feedback was superior to the other methods at helping patients maintain weight-bearing status.7
Amputation and Prosthetics
- A systematic review of studies comparing rigid versus soft dressings after amputation determined that rigid dressings resulted in significantly shorter time from amputation to fitting of a prosthesis.8
- A randomized trial of phantom pain found that a protocol of progressive muscle relaxation, mental imagery, and phantom exercises yielded more significant reductions in the rate and intensity of phantom pain than a program of standard physical therapy.9
Low Back Pain
- Among patients with low back pain, a three-way randomized trial (standard care, standard care + extensible lumbosacral orthoses, and standard care + inextensible lumbosacral orthoses) found that inextensible lumbar orthoses led to a greater improvement in Oswestry Disability Index scores than the other two approaches.10
- Büker N,,Akkaya S, Akkaya N, Gökalp O, Kavlak E, Ok N, Kıter AE, Kitiş A.Comparison of effects of supervised physiotherapy and a standardized home program on functional status in patients with total knee arthroplasty: a prospective study. J Phys Ther Sci. 2014 Oct;26(10):1531-6. Epub 2014 Oct 28.
- Salpakoski A, Törmäkangas T, Edgren J, Kallinen M, Sihvonen SE, Pesola M,Vanhatalo J, Arkela M, Rantanen T, Sipilä S. Effects of a multicomponent home-based physical rehabilitation program on mobility recovery after hip fracture: a randomized controlled trial. J Am Med Dir Assoc. 2014 May;15(5):361-8. Epub 2014 Feb 20.
- Rakel BA, Zimmerman MB, Geasland K, Embree J, Clark CR, Noiseux NO,Callaghan JJ, Herr K, Walsh D, Sluka KA. Transcutaneous electrical nerve stimulation for the control of pain during rehabilitation after total knee arthroplasty: A randomized, blinded, placebo-controlled trial. Pain. 2014 Dec;155(12):2599-611.Epub 2014 Sep 28.
- Mau-Moeller A, Behrens M, Finze S, Bruhn S, Bader R, Mittelmeier W. The effect of continuous passive motion and sling exercise training on clinical and functional outcomes following total knee arthroplasty: a randomized active-controlled clinical study. Health Qual Life Outcomes. 2014 May 9;12:68.
- Huang J, Wang C, Ma X, Wang X, Zhang C, Chen L. Rehabilitation regimen after surgical treatment of acute Achilles tendon ruptures: a systematic review with meta-analysis. Am J Sports Med. 2015 Apr;43(4):1008-16. Epub 2014 May 2.
- Bania TA, Dodd KJ, Baker RJ, Graham HK, Taylor NF. The effects of progressive resistance training on daily physical activity in young people with cerebral palsy: a randomised controlled trial. Disabil Rehabil. 2015 Jun 9:1-7. [Epub ahead of print].
- Fu MC, DeLuke L, Buerba RA, Fan RE, Zheng YJ, Leslie MP, Baumgaertner MR, Grauer JN. Haptic biofeedback for improving compliance with lower-extremity partial weight bearing. Orthopedics. 2014 Nov;37(11):e993-8.
- Churilov I, Churilov L, Murphy D. Do rigid dressings reduce the time from amputation to prosthetic fitting? A systematic review and meta-analysis. Ann Vasc Surg. 2014 Oct;28(7):1801-8. Epub 2014 Jun 6.
- Brunelli S, Morone G, Iosa M, Ciotti C, De Giorgi R, Foti C, Traballesi M. Efficacy of progressive muscle relaxation, mental imagery, and phantom exercise training on phantom limb: a randomized controlled trial. Arch Phys Med Rehabil. 2015Feb;96(2):181-7. Epub 2014 Oct 23.
- Morrisette DC, Cholewicki J, Logan S, Seif G, McGowan S. A randomized clinical trial comparing extensible and inextensible lumbosacral orthoses and standard care alone in the management of lower back pain. Spine (Phila Pa 1976). 2014 Oct 1;39(21):1733-42.
The rate of graft failure following anatomic ACL reconstruction has been reported to be as high as 13%, nearly double the reported failure rate of transtibial reconstructions. The majority of anatomic graft failures occur six to nine months after surgery, when patients commonly return to full sports activity. Findings from a cadaver study by Araujo et al. in the November 4, 2015 edition of The Journal of Bone & Joint Surgery may help explain these phenomena.
The authors used a robotic system to measure in situ forces on 12 native cadaver ACLs and on three different reconstructions, one representing the anatomic approach and two reconstructions approximating traditional transtibial approaches. They measured forces on the grafts during anterior tibial loading and simulated pivot-shift loading.
Araujo et al. hypothesized that an anatomically positioned graft would experience increased in situ forces relative to transtibial positioning, and that is what the study revealed during knee flexion angles of 0°, 15°, and 30°. At 45°, 60°, and 90° of flexion, the transtibially positioned grafts experienced higher in situ loading forces than the anatomic ones.
While this cadaveric study is not the definitive word on this matter, with the high graft forces on the anatomic reconstructions, the authors suggest that “rehabilitation and return to sports progression may need to be modified to protect an anatomically placed graft after ACL reconstruction.”
I selected this study from the July 15, 2015 Journal because it highlights where we need to be headed with innovation for musculoskeletal care. Health care budget pressures and patient satisfaction measurements are pushing us to develop cost-effective care that also offers greater patient convenience.
Dr. Helene Moffet and her colleagues conducted a well-designed, randomized controlled trial, and they found that in-home telerehabilitation was “noninferior” to face-to-face delivery of home-rehab services among more than 200 post-TKA patients. These are important findings, but I surmise that only patients who preferred care in the home and/or were equipped to manage the requisite technology agreed to be randomized. In fact, as Dr. Mark Spangehl observed in his accompanying Commentary, more than one-third of patients assessed for eligibility declined to participate in the study. “Patients who are less motivated or less computer savvy or are technologically adverse may not be able to navigate this type of system,” Dr. Spangehl wrote. Other patients will simply require the human touch to motivate them to work on strength, gait, and range of motion.
So, in addition to developing innovations like this that lower the total cost of care while maintaining or improving its quality, we need to conduct research that will identify the patients who will do well with innovation and those who will do better with more traditional care. Today, this two-pronged type of systems-innovation research is essential for patients and health systems worldwide.
Marc Swiontkowski, MD
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of key findings from studies cited in the November 19, 2014 Specialty Update on orthopaedic rehabilitation:
- Among geriatric hip fracture patients, those who received comprehensive postsurgical care (including a multidisciplinary assessment of health, function, and social situation) had significantly more upright time and better Short Physical Performance Battery scores than counterparts who received hospital physiotherapy and conventional care.
- Seventy-two percent of 51 orthopaedic inpatients exceeded their target goal for prescribed partial weight bearing after being trained. The inability to comply with the training was not associated with poorer outcomes at three months, suggesting clinical support for less-restrictive weight-bearing protocols.
- A prospective study of 38 unilateral TKA patients revealed that results from squatting exercises more accurately predicted overall functional difficulties than did results from standing with increased weight.
- A prospective randomized trial among 36 patients who underwent primary ACL reconstruction with semitendinosus-gracilis autograft found no difference in knee laxity, peak isometric force, or subjective IKDC scores between those who had aggressive early rehabilitation versus those undergoing a nonaggressive protocol.
Pediatric Rehabilitation (focused on cerebral palsy patients)
- Among 100 young children with cerebral palsy, the development of mobility and self-care was faster in children with less severe levels as assessed with the Gross Motor Function Classification System (GMFCS). A separate assessment study supported the validity of the Patient Reported Outcomes Measurement Information System (PROMIS) Mobility Short Form.
- Results from two gait-analysis studies suggested that using gait analysis in planning interventions for children with cerebral palsy can lead to beneficial alterations in gait.
Amputation and Prosthetics
- A study comparing functional outcomes after two types of unilateral transtibial amputation (modified Ertl and modified Burgess procedures) found no significant between-group differences.
Spinal Cord Injury
- A study to assess the safety and efficacy of ReWalk (a lower-limb powered exoskeleton) among 12 patients with motor-complete thoracic spinal cord injury found that all subjects were able to walk independently and continuously for at least 50 to 100 meters. No falls were reported, but a few adverse events related to pressure and irritation occurred.