Collecting a comprehensive evidence base to monitor fracture rehabilitation: A case study

Abstract

Author contributions: Solomon LB designed the study and performed the surgery on both patients included in this study; Callary SA performed the radiostereometric analysis radiographic examinations and subsequent measurements; Rowlands AV performed the activity monitoring; Thewlis D performed the gait analysis and subsequent analysis; all authors contributed to detailed analysis, interpretation of results, and the preparation of the manuscript. Abstract AIM: To determine the feasibility and potential role of combining radiostereometric analysis (RSA), gait analysis and activity monitoring in the follow-up of fracture patients. METHODS:Two patients with similar 41B3 tibial plateau fractures were treated by open reduction internal fixation augmented with impaction bone grafting and were instructed to partial weight bear to 10 kg for the first six postoperative weeks. Fracture reduction and fixation were assessed by postoperative computer tomographic (CT) scanning. Both patients had tantalum markers inserted intra-operatively to monitor their fracture stability during healing using RSA and differentially loaded RSA (DLRSA) at 6 and 12 wk postoperatively. Gait analyses were performed at 1, 2, 6, and 12 wk postoperatively. Activity monitors were worn for 4 wk between the 2 and 6 wk appointments. In addition to gait analysis, knee function was assessed using the patient reported Lysholm scores, and doctor reported knee range of motion and stability, at 6 and 12 wk postoperatively. RESULTS:There were no complications. CT demonstrated that both fractures were reduced anatomically. Gait analysis indicated that Patient 1 bore weight to 60% of body weight at 2 wk postoperative and 100% at 6 wk. Patient 2 bore weight at 10% of body weight to 6 wk and had very low joint contact forces to that time. At 12 wk however, there was no difference between the gait patterns in the two patients. Patient 1 increased activities of moderate-vigorous intensity from 20 to 60 min/d between 2 and 6 postoperative weeks, whereas Patient 2 remained more stable at 20-30 min/d. The Lysholm scores were similar for both patients and did not improve between 6 and 12 wk postoperatively. DLRSA examination at 12 wk showed that both patients were comfortable to weight bear to 80 kg and under this weight the fractures displaced less than 0.4 mm. RSA measurements demonstrated over time fracture migrations of less than 2 mm in both cases. However, Patient 2, who followed the postoperative weight bearing instructions most closely, displaced less (0.3 mm vs 1.6 mm). CONCLUSION:This study demonstrates the potential of using a combination of RSA, gait analysis and activity monitoring to obtain a comprehensive evidence base for postoperative weight bearing schedules during fracture healing.

Radiostereometric Analysis Allows Assessment of the Stability and Inducible Displacement of Pelvic Ring Disruptions during Healing: A Case Series

“…Although computed tomography (CT) scans are capable of detecting small fracture migrations, CT's cannot be used repeatedly due to radiation exposure and cannot typically be used under weight-bearing load conditions. By contrast, radiostereometric analysis (RSA) can accurately measure fracture migration [17][18][19], can be performed at regular intervals without exposing patients to higher radiation doses than regular radiographs [20], and differentially loaded RSA (DL-RSA) can be performed under weight-bearing loads [19,20]. In a subgroup of tibial plateau fractures, DL-RSA measurements have shown that instruction to 'weight-bear as tolerated' resulted in less than 1 mm fracture migrations that were elastic in nature throughout fracture healing [19].…”

Peak loading during walking is not associated with fracture migration following tibial plateau fracture: A preliminary case series

“…Musculoskeletal models have proven to provide reliable estimates of joint loads during motion when experimental measurement is not available. Recently, the feasibility of using this approach to estimate TPF load during level walking gait, has been demonstrated. Investigating the association between fracture migration and fracture loading during movement, by combining data from musculoskeletal modelling and RSA, may provide a better understanding of the factors influencing fracture migration.…”