Extract
Treatment of osteoporotic fractures of the distal part of the femur and the tibial plateau continues to evolve. New developments with regard to implants and operative technique now provide improved means of dealing with the numerous biological and mechanical issues that directly affect osteoporotic patients. These biological and mechanical issues commonly include degenerative joint disease, multiple medical comorbidities, limited prefracture activity levels, multiple fracture planes with lower-energy injuries, and difficulty with postoperative mobilization.
Treatment of osteoporotic fractures of the distal part of the femur and the tibial plateau continues to evolve. New developments with regard to implants and operative technique now provide improved means of dealing with the numerous biological and mechanical issues that directly affect osteoporotic patients. These biological and mechanical issues commonly include degenerative joint disease, multiple medical comorbidities, limited prefracture activity levels, multiple fracture planes with lower-energy injuries, and difficulty with postoperative mobilization.
This patient population has, in general, lower demands and activity levels. While there are some exceptions, the majority of patients with osteoporosis are not running, skiing, or participating in heavy-impact aerobic exercise. Further complicating treatment are the multiple medical comorbidities affecting not only the patient's final function but also the soft-tissue and osseous healing capabilities as well as the ability to recover from prolonged inactivity. Baseline weakness and dementia can dramatically affect an elderly patient's ability to protect the operatively treated extremity. This may lead to the use of additional internal fixation or protective spanning external fixation.
It is important to have a comprehensive understanding of a patient's functional level and comorbidities. Patients with osteoporotic bone are often elderly and may have functional, mental, and metabolic issues that impact the degree of correction necessary as well as their ability to withstand a surgical procedure. When a patient has internal fixation, there are additional issues related to the osteoporotic bone. The most common issue is subsidence of the articular surface during the postoperative period. This is the result of decreased bone quality, the inability of current implants to resist axial loads, and the elderly patient's diminished ability to protect the injured lower extremity during mobilization. These problems make postoperative mobilization a challenge.
The complications inherent in the typical osteoporotic patient population are more challenging when there is preexisting degenerative arthritis of the knee. Degenerative arthritis makes precise anatomic restoration (<2 mm of articular step-off) difficult, if not impossible. Additionally, a knee with degenerative arthritis is less tolerant of mechanical axis deviations; therefore, restoration of normal anatomic and mechanical alignment is critical1,2. Below, we suggest special instruments and make recommendations to assist practitioners in the treatment of fractures in osteoporotic patients with or without degenerative arthritis and to reduce the aforementioned risks associated with this patient group.
Osteoporotic bone often has a direct effect on the fracture pattern. Comminuted, multiplanar, intra-articular fractures around the knee seen in young patients are usually due to high-energy injuries whereas in patients with osteoporosis they are commonly due to a low-energy fall. The soft-tissue injury is usually less severe with lower-energy fractures, often allowing early or immediate fixation. The patient's comorbidities are more likely to be the factor most responsible for soft-tissue compromise.
A simple distal femoral shaft fracture can usually be treated with either retrograde or antegrade nail fixation. However, a supracondylar femoral fracture is different. When a fracture is distal to the metaphyseal flare, there is less bone available for fixation and there is a risk of malreduction. Treatment of a supracondylar fracture can be further complicated by the presence of a total knee replacement.
The operative goal for a patient with a total knee replacement and a supracondylar fracture is, in general, restoration of the prefracture alignment. This is because correcting malaligned arthroplasty components results in either fracture gaps or a tilted joint line, as the tibial component is not altered to match the new femoral position. When the femoral component is not well fixed, a revision total knee arthroplasty with a stemmed component is the preferred treatment option.
Evaluation and Planning
Evaluation and planning begin with obtaining the appropriate imaging studies. For femoral fractures, a complete set of plain radiographs that include the knee, femoral shaft, and hip should be made. In addition, if there is any suspicion that the fracture has entered the joint, a fine-cut computed tomography scan with sagittal and coronal reconstructions should be performed.
For fractures of the femur, it is particularly important to take into account the unique circumstances of patients with osteoporotic bone when choosing an implant. Poor bone quality and the possibility of metastatic bone disease are indications for selecting the longest implants available. Short retrograde nails and short locked plates should be avoided, as they produce stress-risers in the midpart of the diaphysis. Long implants improve the biomechanical strength of fracture fixation constructs as well as protect the entire length of the bone. Long locked plates provide axial stability in highly unstable fracture patterns and improved fixation in osteoporotic bone3-5.
Positioning and Approach
Malalignment can occur with any of the implants discussed in this paper. To improve fracture reduction, the patient should be totally paralyzed. A roll should be used to correct flexion/extension deformity, with gentle traction applied to the leg, if necessary, to correct varus/valgus alignment (Fig. 1). Several other important points with regard to determining the appropriate positioning and approach are specific to the implant that will be used and are discussed in the following section.
Choice of Implants
Retrograde Nail
It is important to understand the most common problems associated with the use of a retrograde nail. These include malalignment due to a poor starting point, flexion malalignment as a result of the knee flexion required for access to the joint during reaming and nail placement, and insufficient distal stability. Also, there are issues with regard to total knee replacements with fixed components and potentially uncontrollable malalignment.
Flexion of the knee so that the tibial plateau is not in the way is necessary to place a retrograde intramedullary nail. Even with the patient paralyzed, this maneuver generally flexes the distal fragment. It is tempting to move the starting point posteriorly to introduce more extension, but this produces anterior translation. The solution is to use provisional pin fixation from the medial and/or lateral condyle with the knee in extension and limited roll support under the fracture site. The large intramedullary diameter of the distal part of the femur almost always allows room for both the pins and the reamers and nail. Provisional stabilization of the fracture makes it possible to flex the knee to gain access without producing a deformity at the fracture site.
The anatomy of the distal part of the femur allows good osseous contact of the retrograde nail in the subchondral region but no contact at the fracture site. As a result, the starting point for a retrograde nail determines flexion, extension, varus, valgus, and multidirectional translation. The ideal site for entry of a retrograde nail into the distal part of the femur has been well described, and, while absolute precision is not necessary, variance of more than several millimeters can be a problem6.
In the vast majority of femora, the optimal entry site, in line with the long axis of the femur, is located 6 to 8 mm anterior to the posterior cruciate ligament insertion and slightly medial to the center of the intercondylar groove. The distal fracture fragment can be directly manipulated with use of bone clamps or Steinmann pins, but the deforming forces due to a misplaced starting hole often cannot be overcome. Starting too anterior or posterior results in flexion/extension deformity, and starting too medial or lateral results in translation of the distal fragment in the opposite direction unless varus or valgus deformity is accepted. Thus, the starting point for the retrograde nail is perhaps the most important and technically challenging part of the surgical procedure. Slight deformity at the fracture site can generally be manually corrected prior to placing distal interlocking screws as long as close attention was paid to the initial entry site. For proper placement of the initial entry site, the starting guidewire should be inserted with fluoroscopic confirmation in two planes and to a depth of at least 8 to 10 cm so that actual alignment and orientation can be confirmed prior to drilling a larger entry hole.
When a patient has a periprosthetic supracondylar fracture in the femur, the approach may be limited by the previous surgery and the implant position. A femoral component that is medial or lateral in relation to the femoral shaft causes displacement of the distal fragment in the opposite direction when retrograde nail fixation is used. Similarly, if the femoral component is in excessive flexion or extension, the postfixation alignment will be opposite to this original deformity (Fig. 2). An open-box total knee arthroplasty implant with metal extending posteriorly causes a similar deformity. In this circumstance, an extension deformity is produced by the retrograde intramedullary nail. There are situations in which a retrograde nail cannot be used because of the position or type of total knee replacement, and in those instances a locked supracondylar plate is preferred.
Another limitation of retrograde nail fixation for these fractures that is beyond the control of the surgeon is the poor cancellous bone, even when multiple interlocking screws are used7. Many systems include an interference screw that can be placed in the most distal screw hole to convert the nail to a fixed-angle device. However, these systems still fail because the osteoporotic cancellous bone is inadequate, and it is not uncommon for these distal femoral fractures to drift into valgus at the site of the nail fixation.
Additional stability as well as some degree of angular correction can be achieved with blocking screws placed in the distal fracture fragment. The blocking screws must be in direct contact with the nail. To accomplish this, the drill used for the blocking screw should partially overlap the nail on the fluoroscopic image so that the nail deflects the drill as it passes from anterior to posterior. This technique ensures that the blocking screw will directly impinge against the nail, providing the desired stability.
Locked Supracondylar Plate
A number of the issues associated with retrograde nail fixation, the most important of which is distal fixation and stability, are addressed by using a locked supracondylar plate. The common issues related to the use of locked supracondylar plates for extra-articular distal femoral fractures are appropriate plate length, malalignment, and interference with total knee arthroplasty pegs. Multiple locked screws in the distal part of the femur offer better overall stability and less motion after cyclic loading than do retrograde nails, and the success of these plates has been reported in clinical series3,8. Unfortunately, they bring their own new technical challenges.
Plate length is important in a patient with osteoporosis, both for fixation of the condylar fragment and to avoid creation of stress risers in the femoral shaft. Use of a long plate, while leaving some screw holes without screws, provides better fixation with less of a chance of failure at the proximal part of the diaphysis due to either pull-out of screws or a fracture at the tip of the plate9. There is no absolute rule for implant length, but it has been recommended that a lateral locked plate extend past the midpart of the diaphysis.
Medium-sized pins can be used for provisional fixation, and percutaneous techniques are recommended for placement of the long locking implant. In the absence of a prefracture deformity, the reference wire and subsequently used locked screw should be parallel to the joint surface. We prefer placing the reference wire with a distal clamp in place, clamping or lagging the diaphysis to the plate, and confirming alignment before placing any distal locked screws (Fig. 3). When varus/valgus alignment is acceptable, any flexion/extension deformity can be corrected with the reference pin in place by manipulating the distal fragment either directly or by adjusting the roll under the lower limb. When the amount of comminution causes a large medial gap when the limb is brought to its proper length, it is better to accept shortening and achieve bone contact than to leave the gap. The same issues of prefracture implant position and risk of malalignment that were identified for intramedullary fixation in a patient with a fracture and a total knee replacement apply to the use of plate fixation in such a patient. The pegs in the femoral component can create problems. The reference wire and screw may pass them, while one or more of the distal locked screws will impinge on or be blocked by them. Polyaxial locked screws are available and can be used in this situation. The stability and strength of polyaxial systems are adequate, and they allow the locked screws to be in direct contact with the prosthesis, which prevents osteopenic bone failure around the more rigid implant10.
Clamps on the distal fracture fragment can penetrate osteoporotic bone and reduce bone stock. Using the so-called lunar-lander attachments on large periarticular clamps minimizes this risk. Large locked supracondylar femoral plates are difficult to revise, so one must be sure that the alignment is acceptable before the majority of the distal locked screws are placed. Intraoperative plain radiographs are recommended.
The challenges presented by intra-articular distal femoral fractures through osteoporotic bone are similar to those presented by such fractures through normal bone. The interventions for both injuries have the common goals of joint reduction, restoration of axial alignment, and early motion. Simple unicondylar fractures can be managed with direct exposure and buttress plate fixation. In contrast, locked supracondylar plates have made almost all other implants obsolete for the treatment of more complex bicondylar fractures. Complex comminuted fractures in osteoporotic bone are often due to low-energy injuries, and, as a result, early definitive fixation is often possible. The issues specifically related to patients with osteoporotic bone are the need and/or desire for disimpaction of the articular surface, acceptance of shortening, and the potential need for bridging or protective external fixation.
When the distal articular surface of the femur is compressed or impacted, elevation is difficult and restoration of the natural curved contour is almost impossible. This impaction pattern is more common in osteoporotic bone. Even when the articular surface can be elevated successfully, providing structural support beneath it becomes difficult. The choice is between accepting 1 to 2 mm of impaction in the weight-bearing surface or disimpacting the fragments and struggling to hold them in place. This decision is made on an individual basis, and it is important to recognize the inherent limitations and goals of the treatment of this injury.
Restoring anatomic length is less important than restoring overall axial alignment and achieving successful healing. After the articular surface has been restored to an acceptable degree, varus/valgus and flexion/extension alignment are obtained with use of the techniques discussed previously in this paper. The stability of the construct is determined after the joint has been reduced, alignment has been restored, and a long locked plate has been secured.
Fragmentation of the distal fracture fragment is the cause of early failure of the more complex intra-articular fractures in osteoporotic bone. While interfragmentary screw fixation outside the plate helps to minimize this risk, additional protection may be needed. A bridging external fixator may be employed because use of a brace or cast is insufficient. Applying an external fixator to the femur is difficult when there is a long plate; therefore, a shorter plate is often chosen when the possible use of a supplemental external fixator is anticipated. The fixator is placed in a neutral position so that the locked plate construct is protected rather than stressed by the fixator. In addition, neutral or slight distraction of the joint, not compression, should be the goal. We prefer to have the knee in full extension, and we remove the frame at six to eight weeks.
Treatment goals for tibial plateau fractures in osteoporotic bone are the same as those for such fractures in normal bone. These goals are to restore articular congruity, limb length, anatomic rotation and alignment, sufficient stability for union, and function. However, the usual techniques require modifications in the presence of weak osteoporotic bone.
A patient's functional abilities are an important consideration, as those with limited function may not require the same degree of correction as those with greater function. Additionally, elderly patients may have several comorbidities that make it unlikely that they can tolerate a long operative procedure. Midway through a dual approach to a bicondylar tibial plateau fracture is not the time to suspend the operation. Instead, a planned staged procedure may be more desirable for the patient and the surgical team.
Evaluation and Planning
A complete set of plain radiographs is essential. For tibial plateau fractures, this set should include four views of the knee and two views of the entire tibia. A fine-cut computed tomography scan with coronal and sagittal reconstructions should be obtained for all fractures. If a fracture is axially unstable or associated with severe soft-tissue damage, joint-spanning external fixation should be placed before the computed tomography is performed.
The displacement of the unstable segment of the tibial plateau will be evident on inspection of the initial plain radiographs, and the direction of the displacement determines the position of the dominant segment. The computed tomography scans and plain radiographs will clearly demonstrate the depressed articular fracture components. It is important to determine if the tibial tubercle is a free segment; if it is, it needs to be affixed to the distal part of the tibia. This may require additional implants to buttress the articular segments and fix the articular surface to the tibial shaft. Depressed articular segments are elevated regardless of whether they are medial or lateral. Most depressed articular fragments involve the lateral tibial plateau, but their position in the lateral condyle varies with the fracture pattern. Displaced metaphyseal-diaphyseal fragments are buttressed to the tibial shaft. The most common buttress plate positions are posteromedial and anterolateral, and not unexpectedly the most frequent surgical approaches are posteromedial and anterolateral.
Special Instruments
The surgical treatment of osteoporotic bicondylar fractures requires the same special instruments used for bicondylar fractures in normal bone. Key instruments are a complete set of bone tamps, including the curved tamps; a set of curved and straight osteotomes; and a large femoral distractor.
Patient Positioning
The patient is positioned supine on a radiolucent flat-top operating table with the ipsilateral arm across the chest. As a first step, the external rotation of the hip must be evaluated. If the patient has normal external rotation and an isolated tibial plateau fracture, no further positioning of the trunk is necessary. If the patient has an isolated tibial plateau fracture and restricted external rotation of the ipsilateral hip, a 6-in (15.2-cm)-diameter bump extending from under the ilium to the scapula positions the patient so that the patella points toward the ceiling. Additional bumps or a wedge may be necessary to support a rigid thoracic kyphosis, an ankylosed lumbar spine, or a rigid arthritic cervical spine. To allow easy access to the medial and lateral sides of the plateau and unobstructed imaging with the image intensifier, the leg that is to be operated is elevated on additional bumps. The patient's thorax and contralateral leg are then secured to the operating table. A well-padded tourniquet is applied to the proximal part of the thigh.
The image intensifier should be brought in from the contralateral side in most cases, but when the medial side is the most involved the intensifier is brought in from the ipsilateral side. The image intensifier is used while the depressed fracture fragments are elevated with the bone tamp, the osteotome is positioned, and the amount of joint elevation and reduction is determined.
Choice of Approach
Careful attention to the soft tissue is important, particularly in elderly patients. In general, the tourniquet is not inflated unless it is necessary to improve visualization when the articular cartilage surface is being reduced. One should also avoid using self-retaining retractors; instead, handheld Sofield or Langenbeck retractors should be employed to minimize tension on the skin. Electrocautery is used sparingly during the initial dissection to minimize thermal injury to the dermis and subcutaneous tissues. Anterolateral flaps are elevated along with the deep fascia of the anterior compartment; the maximal safe medial extension of the lateral dissection is the lateral aspect of the tibial tubercle. The diaphyseal components of long periarticular plates are placed submuscularly and extraperiosteally.
There are key points specific to the lateral approach. We use a lazy-S incision to the lateral plateau because it does not compromise the iliotibial band and can be easily extended proximally and distally, but an L-shaped approach is useful particularly if the primary aim of the lateral approach is joint elevation. The extensile medial approach is essential for the treatment of medial joint depression and fracture displacement. We use this approach for treating Schatzker11 type-4 tibial plateau fractures (Fig. 4) and certain bicondylar tibial plateau fractures. The posteromedial fragment of the medial plateau can be properly buttressed only through the medial approach. When there is associated medial depression of the medial plateau, it can be elevated under direct visualization by using a submeniscal approach between the superficial and deep medial collateral ligaments. Release of the insertion of the semimembranosus from the proximal part of the tibia and the lateral aspect of the gastrocnemius from the femur allows maximal exposure, when necessary.
Methods of Joint Elevation and Grafting
Articular impaction typically occurs on the lateral side. Unlike the focal depressed segments observed in normal bone, the depressed segments in osteoporotic bone often are diffuse and multifragmentary and involve most of the tibial plateau. Often, the depressed segment is a thin section of corticocancellous subchondral bone lying above a cavitated metaphyseal-diaphyseal segment (Fig. 5). This affects the choice of the bone graft, the method of fixation, and the approach. The meniscus in an elderly patient is typically firm and friable. Despite this, it is important to repair the meniscus to protect the articular surface. A submeniscal arthrotomy is performed to visualize the articular surface and facilitate the meniscal repair. Prior to the arthrotomy, a lateral femoral distractor is placed; one 5-mm Schanz pin is inserted in the distal part of the femur, and one 5-mm pin is placed in the lateral part of the tibia, distal to where the lateral plate is to be applied. The submeniscal arthrotomy leaves the coronary ligament inferior to the meniscus, which often appears bluish as a result of hemarthrosis, attached to the tibial plateau. A linear incision is first made parallel to the tibial plateau to ensure that the exposure is submeniscal. Once it is established that the incision is submeniscal, it is extended anteriorly and posteriorly. If the femoral condyle is visible, the meniscus is torn. If the meniscus is not visible, it is either trapped in the articular depression or flipped into the intercondylar notch. The meniscus often remains attached at its anterior and posterior horns. Varus stress to the joint with the femoral distractor permits visualization of the joint, and a Freer elevator can be used to free the meniscus and restore it to its native position. Temporary sutures placed in the periphery of the meniscus are used to aid in its retrieval. Number-1 or 0 sutures are placed perpendicular to the meniscus sequentially, from posterior to anterior through the periphery, and individually held with hemostats.
Critical to the treatment of tibial plateau fractures with joint depression is elevation of the depressed segment, and this is particularly true for patients with poor bone quality. Elevation of the articular surface is performed under direct visualization. All attempts are made not to window open the lateral plateau fragments so that the periosteal ring of the proximal plateau is maintained. This prevents loss of containment of the multiple fragments of the tibial plateau. If the lateral split opens inadvertently during the approach, it can be gently opened fully for en bloc elevation of the articular surface. In cases in which the rim opens, the articular surface is elevated remotely (1 to 1.5 cm distal to the articular surface) with a wide osteotome acting as a skid. All impacted cancellous bone all of the way around the fragment should be freed up before attempting to elevate the depressed fragment (Fig. 6).
When the periphery of the plateau is intact, the depressed segment is elevated remotely on a "cloud" of bone. When the depressed articular segment is clearly visible through the arthrotomy site, the image intensifier is less necessary. A corticotomy of the anterolateral aspect of the tibia is created by drilling four holes with a 2.5-mm drill bit in a rectangular pattern in the anterolateral aspect of the cortex just inferior to the lateral flare of the plateau. Once created, the drill-holes are connected with a 1-cm osteotome to create a cortical window. Bone graft is impacted with bone tamps through the remote corticotomy with or without the aid of an image intensifier. The impacted bone graft will elevate the articular surface (Fig. 7). Use of gentle taps with a mallet to impact and elevate is a more controlled technique than gross movements of the hand. One must beware of inadvertent chondral perforation with the osteotome or bone tamps. Once the articular surface is elevated, provisional subchondral 0.062-in (0.157-cm) Kirschner wires support the articular surface. These may be retained or removed after so-called raft screws have been placed through a periarticular plate or rim plate. "Raft," or "rafter," screws refer to a series of parallel or slightly divergent screws placed in a single plane just below the elevated articular surface. Their purpose is to act like the rafters in a roof and support the newly elevated articular surface.
Once elevated, the depressed articular segment is supported with bone graft or bone-graft substitute. Allograft is ideally suited in these cases because it is available in almost unlimited quantities, is inexpensive, readily osteointegrates, can be impacted very densely, can be fine-tuned to a size that is ideal for elevation and support, and is more reliably directed than injectable cements. Both allograft and autograft, however, may be more likely to subside than biological cements12. Allograft may also be less than ideal in very osteoporotic patients if it is harder than the native bone, as it creates a risk of fragmentation of the subchondral surface during elevation.
There is increasing evidence supporting the use of biological cements, despite their increased cost compared with allograft and autograft. The osteointegration of the biological cements and the durability of subchondral support vary with the composition of the cement, and the surgeon must evaluate each cement to ensure its appropriateness. Clinical and basic-science data support the use of biological cements to facilitate early weight-bearing, which may be advantageous for the elderly.
The bone cements cannot be used to elevate the articular surface; this must be done manually by the surgeon. The elevated articular surface must be sealed to prevent extravasation of the cement into the knee joint, and the field must be as dry as possible before the cement is placed. Placing the biological cement in a warmer prior to use speeds up the setting process, thereby avoiding "wash-away" by blood. Additionally, these fillers are not intended to be drilled and instruments cannot be inserted into them. Thus, the cement must be used after the hardware is placed, or it must be injected into places where hardware is not intended to go. We use biological cements to fill large metaphyseal voids after joint elevation has been achieved (with or without allografting) and often after the instrumentation has been placed. In this setting, the cements prevent joint subsidence and protect the fixation construct during the initial phases of weight-bearing13,14.
Choice of Implants
The implants used depend on the fracture type. As a general rule, multiple small articular raft (or rafter) screws provide better subchondral support than do a few large raft screws15,16. Depressed and minimally displaced split depressed unicondylar fractures are fixed with raft screws and nonlocked periarticular plates. When the contralateral condyle is osteoporotic, we use a periarticular locked plate so that the articular raft is fixed to the plate and not completely dependent on medial cortical support. Bicondylar fractures with a large minimally displaced medial fragment are treated with a lateral locked plate. If there is medial metaphyseal-diaphyseal comminution, a simple medial percutaneous plate can be added to prevent varus deformity (Fig. 8). We recommend a medial locked plate, in addition to the posteromedial buttress plate, to fix fractures with metaphyseal-diaphyseal comminution (Fig. 6) because the currently available locked plates do not adequately address the posteromedial fragment4,17. The medial plate is initially fixed to the shaft, and medial raft screws are not placed completely across the tibial plateau until the lateral plateau has been elevated and the width of the tibial plateau has been corrected. The correction of plateau width occurs after the lateral plateau has been elevated and the lateral buttress plate or lateral locked plate is in its provisional position and provisionally fixed with Kirschner wires to the tibia.
As discussed previously, there are occasions when bone quality is so poor that stability is inadequate despite multiple approaches and the aggressive use of locked plates. In these situations, bridging external fixation should be used to protect the reconstructed joint. As is the case with distal femoral fractures, the pins should be placed at least several centimeters away from any deep hardware, the knee should be kept in full extension, and the frame should be in a neutral position so that it does not load the restored joint in any way. The frame is left in place for six to eight weeks, and passive, active, and active-assisted range-of-motion exercises are begun immediately after removal. However, weight-bearing is delayed until twelve weeks after the operation.
Closure
The wounds should be closed in layers, with Hemovac drains (if necessary) placed in the deepest layer against the bone. It is very important to have a secure fascial layer over the lateral plate, and, if necessary, a fascial release is performed posteriorly in the lateral compartment to achieve this coverage. The subcutaneous and fascial layers are closed with 2.0 absorbable sutures. The skin is closed with 3.0 nylon sutures placed in a Donati-Allgower fashion or with use of an alternate retention suture technique.
Postoperative management of an elderly patient with osteoporotic bone is complicated by a loss of upper-extremity muscle mass and decreased core strength, which make non-weight-bearing on the injured extremity extremely difficult. The use of crutches or a walker to protect a lower extremity of an elderly person is difficult and may result in partial weight-bearing. We prefer for the patient to use a wheelchair if he or she is unable to protect the extremity. Elderly patients often need to be kept non-weight-bearing for twelve weeks, especially after internal fixation of a complex axially unstable fracture. At three to four weeks after surgery, mobilizing patients in a pool with water at the level of the shoulders is considered to be safe and beneficial. A knee immobilizer is also used for the first two weeks to protect the wound, with supervised gentle range-of-motion exercises usually started as soon as the wound can tolerate motion. A team approach with the aid of a geriatric provider or hospitalist may improve the patient's care.
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