A comparative study of 30 cases of fracture neck femur in young adult patients treated with partially threaded cannulated screw versus fully threaded cannulated screws

Background: Fracture neck femur (FNF) is important due to its high incidence in general population. In younger patients, trauma is the major cause of fracture neck femur. Displaced fractures are usually treated by fixation with partially threaded cannulated screws (PTS) placed in a parallel pattern. In the present study, we have explored the use of fully threaded cannulated screws (FTS) for fixation of fracture neck of femur. Aim and Objectives: The aim of our study was to analyze and compare the clinical and functional outcomes of fracture neck femur treated in both groups. Materials and Methods: A prospective randomized control analysis was conducted in the Department of Orthopedics of Rajindra Hospital and Government Medical College, Patiala, Punjab between June 2019 and December 2021 on 30 patients who were admitted with neck femur fracture in the age group between 15 and 60 years. Fifteen patients were treated with FTS and 15 were treated with PTS. Subsequent hip radiographs were taken postoperatively and analyzed for various parameters such as fracture fixation, fracture union, and reduction. Regular follow-up was done by clinical examination along with the radiological examination monthly for 3 months, then at 6th month, and 9th month. The functional outcomes of fracture neck femur treated with PTS and FTS were compared in terms of blood loss, radiological union, weight bearing, functional outcomes (in terms of Harris hip score), and post-operative complications. Results: Hip function on the operated side was evaluated and compared with the normal side as per Harris hip score. About 73.3% of patients with FTS group in this study had excellent results compared to 26.6% in PTS group, fair results were found in 13.3% in both groups, 6.6% of patients had good results with FTS group as compared to 13.3% of PTS group, and 6.6% had poor outcome with FTS group as compared to 46.6% with PTS group. In our study, mean Harris hip score was 76.6 in PTS group and 85.5 in FTS group (P = 0.044). The present study indicated that there were statistically significant differences between FTS and PTS in terms of functional outcomes and complication rates such as femoral neck shortening (P < 0.05). However, no significant differences in terms of blood loss, weight bearing, and fracture union time were observed between two groups (P > 0.05). Conclusions: FNF treated with FTS is superior than PTS in terms of functional outcomes and complication rates. Both FTS and PTS are equivalent in terms of average blood loss, weight bearing, and fracture union time.

Tratamiento de no unión de fractura de escafoides con tornillos canulados sin cabeza e injerto autólogo esponjoso de radio distal / Treatment for non-union scaphoid fractures with headless cannulated screws and distal radius cancellous autograft

Resumen: Introducción: las fracturas de escafoides representan 50-80% de las fracturas de los huesos del carpo. De las fracturas de escafoides 10% evolucionan a no unión con tratamiento conservador y presentan cambios degenerativos en el carpo en 75-97% a cinco años y en 100% a 10 años. El objetivo de este trabajo fue evaluar la tasa y tiempo de consolidación en pacientes con diagnóstico de no unión de fractura de escafoides, sin fragmentación del polo proximal, tras tratamiento con dos tornillos canulados sin cabeza e injerto autólogo esponjoso de radio distal. Material y métodos: serie de casos de cuatro pacientes con diagnóstico de no unión de fractura de escafoides sin fragmentación del polo proximal, tratados mediante reducción abierta y fijación interna utilizando dos tornillos canulados sin cabeza y toma más aplicación de autoinjerto esponjoso de radio distal. Todos recibieron el mismo tratamiento postoperatorio y se tomó control radiográfico para evidenciar consolidación una vez que el paciente experimentó resolución clínica. Resultados: la tasa de consolidación radiográfica fue de 100% con un tiempo de consolidación promedio de 11.25 ± 3.4 semanas. No presentaron complicaciones y no fue necesaria una cirugía de revisión. Conclusión: el resultado del uso de dos tornillos canulados sin cabeza y toma más aplicación de autoinjerto óseo esponjoso de radio distal avala la técnica como una opción efectiva y segura para el tratamiento de no unión de fracturas de escafoides sin fragmentación del polo proximal.

Abstract: Introduction: scaphoid fractures comprise 50-80% of the fractures of the carpal bones. Ten percent of the scaphoid fractures evolve to non-union and show degenerative changes in the carpus in 75-97% at five years and in 100% at 10 years. The objective of this work was to evaluate the rate and time to union in patients with diagnosis of scaphoid non-union without fragmentation of the proximal pole after treatment with two cannulated headless screws and distal radius cancellous autograft. Material and methods: case series with short-term follow-up of four patients with scaphoid non-union without fragmentation of the proximal pole treated by internal fixation using two cannulated headless screws and distal radius cancellous bone autograft. All received the same postoperative treatment and radiographic control was taken as soon as the patient experienced clinical resolution. Results: the radiographic union rate was 100% with an average time to union of 11.25 ± 3.4 weeks. There were no complications and revision surgery was not necessary. Conclusion: the results of the use of two cannulated headless screws and distal radius cancellous bone autograft endorses the technique as an effective and safe option for the treatment of scaphoid non-union without fragmentation of the proximal pole.

Fracturas subtrocantéricas periosteosíntesis tras fijación de fracturas de cuello femoral con tornillos canulados / Periosteosynthesis subtrochanteric fractures after fixation of femoral neck fractures with cannulated screws

Resumen: Introducción: el objetivo del presente estudio fue analizar la incidencia y factores predisponentes en las fracturas subtrocantéreas sobre caderas tratadas previamente con tornillos canulados tras sufrir una fractura subcapital, con base en ocho casos registrados en los últimos 20 años. Material y métodos: se trata de un estudio retrospectivo observacional sobre una serie de pacientes con el diagnóstico de fractura subtrocantérica de cadera, los cuales habían sido tratados en los últimos meses de una fractura subcapital de la misma cadera mediante osteosíntesis con tornillos canulados. El período de estudio fue de 20 años (2000-2020). Resultados: de los ocho casos, cinco eran mujeres y tres hombres, con una media de edad de 75.12 años (rango 59-87 años). En todos los casos, la fractura subtrocantérica ocurrió antes de un año tras la primera fractura, el tiempo transcurrido entre las dos fracturas fue de cuatro meses de media (rango de uno a nueve meses). En cuanto a la disposición de los tornillos canulados, la mayoría de casos 7/8 fue en forma de triángulo de vértice superior y sólo un caso en forma de triángulo invertido o vértice inferior. El punto de entrada en la cortical externa femoral fue a nivel del trocánter menor en seis casos y en dos casos dicha entrada era distal al trocánter menor. Conclusión: según nuestra experiencia, en la etiología de las fracturas subtrocantéricas, la introducción de los tornillos distales al trocánter menor y la distribución de los tornillos en forma triangular son los dos factores predisponentes objetivables principales.

Abstract: Introduction: the objective of this study was to analyze the incidence and predisposing factors in subtrochanteric fractures on hips previously treated with cannulated screws after suffering a subcapital fracture, based on eight cases registered in the last 20 years. Material and methods: this is a retrospective observational study on a series of patients with a diagnosis of subtrochanteric hip fracture, who have been treated in recent months for a subcapital fracture of the same hip by osteosynthesis with cannulated screws. The study period was 20 years (2000-2020). Results: of the eight cases, five were women and three were men, with a mean age of 75.12 years (range 59-87 years). In all cases, the subtrochanteric fracture occurred within a year after the first fracture, the time elapsed between the two fractures was four months on average (range 1-9 months). Regarding the disposition of the cannulated screws, most of the 7/8 cases were in the shape of an upper vertex triangle, and only one case was in the shape of an inverted triangle or lower vertex. The entry point into the femoral external cortex was at the level of the lesser trochanter in six cases, and in two cases this entry was distal to the lesser trochanter. Conclusion: in our experience, in the etiology of subtrochanteric fractures, the introduction of screws distal to the lesser trochanter, and the distribution of the screws in a triangular shape are the two main objective predisposing factors.

Fracturas avulsivas tibiales del ligamento cruzado posterior fijadas con tornillos: un estudio clínico y radiológico / Screw fixation of posterior cruciate ligament tibial avulsion fractures: a clinical and radiographic study

OBJETIVO: Realizar la evaluación clínica, imagenológica y funcional de pacientes con fracturas avulsivas tibiales del ligamento cruzado posterior (FTALCPs) fijadas con tornillos canulados con técnica abierta. MÉTODOS: Los pacientes con FTALCP operados entre 2010 y 2017 fueron revisados retrospectivamente. Criterios de inclusión: fracturas agudas, desplazadas, test de cajón posterior grado III, lesiones combinadas de rodilla, seguimiento > 12 meses. Se excluyeron pacientes > 65 años, con FTALCPs bilaterales, lesiones del ligamento cruzado posterior (LCP) intrasustancia, test de cajón posterior grados I-II, fracturas expuestas, lesiones neurovasculares, y seguimientos < 12 meses. Objetivo primario: medir la estabilidad clínica mediante test de cajón posterior y radiografía de estrés arrodillada comparativa. Objetivos secundarios: nvaluar la consolidación en radiografías, complicaciones y funcionalidad con las escalas de Lysholm y Tegner. Resultados Se incluyeron 20 pacientes, con edad media de 41 años (rango: 32 a 61 años). El seguimiento promedio fue de 33,9 meses (rango: 12 a 82 meses). La estabilidad clínica mejoró en 93% (cajón posterior postoperatorio grados 0 y I) de los pacientes. La radiografía de estrés arrodillada mostró una diferencia promedio de 2,6 mm (rango: 0,1 mm a 6,8 mm) de traslación posterior al comparar con el lado sano. Todas las fracturas consolidaron. Siete pacientes presentaron complicaciones. El puntaje promedio de la escala de Lysholm al final del seguimiento fue de 85,17. El promedio preoperatorio del puntaje en la escala de Tegner no varió significativamente en comparación con el postoperatorio. CONCLUSIONES: La fijación de fracturas avulsivas tibiales del LCP con tornillos canulados con técnica abierta es efectiva en restaurar la estabilidad posterior y lograr la consolidación ósea. La funcionalidad clínica a mediano plazo es buena, a pesar del alto número de complicaciones y lesiones concomitantes. NIVEL DE EVIDENCIA: tipo IV.

OBJECTIVE: To report mid-term clinical, radiographic, and functional outcomes following open reduction and fixation of posterior cruciate ligament tibial avulsion fractures (PCLTAFs) with cannulated screws. METHODS: This is a retrospective analysis of patients with PCLTAF operated on from August 2010 to April 2017. Patients with acute fractures, with more than 2 mm of displacement and grade III on the posterior drawer test, combined or not to knee injuries, were included. Patients older than 65 years of age, with bilateral avulsion fractures, intrasubstance posterior cruciate ligament (PCL) lesions, stable grade-I to -II on the posterior drawer test, concomitant neurovascular injuries, mid-substance tears, open fractures, and less than 12 months of follow-up were excluded. Primary outcomes: the clinical stability was assessed using the posterior drawer test and a single comparative knee stress radiograph. Secondary outcomes: radiographic consolidation, complications, Lysholm score, and Tegner activity score. RESULTS: In total, 20 patients with a mean age of 41 years (range: 32 to 61 years) were included. The mean follow-up was of 33.9 months (range: 12 to 82 months). Clinical stability (grade 0 or I on the posterior drawer test) was observed in 93% of the patients. The mean difference in contralateral posterior displacement was of 2.6 mm (range: 0.1 mm to 6.8 mm) on a single comparative knee stress radiograph. All fractures presented radiological consolidation. Seven patients developed complications. The mean Lysholm score at the last follow-up visit was of 85.17. The postoperative Tegner activity scores did no vary significantly compared to the preinjury scores. CONCLUSIONS: Cannulated screw fixation of a displaced PCLTAF through a posterior approach restores clinical and radiographic stability and has excellent union rates. The mid-term functional outcomes are good despite the high rates of combined knee lesions and postoperative complications. LEVEL OF EVIDENCE: IV.

A meta-analysis of different internal fixation strategies of Pauwels III femoral neck fractures / 上海交通大学学报（医学版）

Objective • To compare the clinical and functional outcomes of cannulated screw (CS) with sliding hip screw (SHS) in the fixation of Pauwels III femoral neck fractures systematically. Methods • In the meta-analysis, articles were searched from Pubmed database, Embase database, Cochrane library, CNKI database, and Sinomed database. The selected articles were analyzed by Revman 5.26 software. Results • Six clinical studies met the inclusion criteria. A total of 350 patients including 213 with CS fixations and 137 with SHS fixations were pooled in the meta-analysis. The results showed that the non-union rate in SHS group was significantly lower than that in CS group. However, the surgery time was significantly shorter in CS group. Conclusion • SHS fixation has the advantage of reducing postoperative non-union rate in Pauwels III femoral neck fractures, but the operative process is relatively complicated, which seemingly causes more blood loss during surgery, and may lead to a less satisfactory functional recovery.

Biomechanical Comparison Study of Three Fixation Methods for Proximal Chevron Osteotomy of the First Metatarsal in Hallux Valgus

BACKGROUND: Fixation of proximal chevron metatarsal osteotomy has been accomplished using K-wires traditionally and with a locking plate recently. However, both methods have many disadvantages. Hence, we developed an intramedullary fixation technique using headless cannulated screws and conducted a biomechanical study to evaluate the superiority of the technique to K-wire and locking plate fixations. METHODS: Proximal chevron metatarsal osteotomy was performed on 30 synthetic metatarsal models using three fixation techniques. Specimens in group I were fixated with K-wires (1.6 mm × 2) and in group II with headless cannulated screws (3.0 mm × 2) distally through the intramedullary canal. Specimens in group III were fixated with a locking X-shaped plate (1.3-mm thick) and screws (2.5 mm × 4). Eight metatarsal specimens were selected from each group for walking fatigue test. Bending stiffness and dorsal angulation were measured by 1,000 repetitions of a cantilever bending protocol in a plantar to dorsal direction. The remaining two samples from each group were subjected to 5 mm per minute axial loading to assess the maximal loading tolerance. RESULTS: All samples in group I failed walking fatigue test while group II and group III tolerated the walking fatigue test. Group II showed greater resistance to bending force and smaller dorsal angulation than group III (p = 0.001). On the axial loading test, group I and group II demonstrated superior maximum tolerance to group III (54.8 N vs. 47.2 N vs. 28.3 N). CONCLUSIONS: Authors have demonstrated proximal chevron metatarsal osteotomy with intramedullary screw fixation provides superior biomechanical stability to locking plate and K-wire fixations. The new technique using intramedullary screw fixation can offer robust fixation and may lead to better outcomes in surgical treatment of hallux valgus.

Cannulated screws plus separate vertical wirings for fixation of acute patella inferior pole fracture / 中华创伤杂志

Objective To investigate the feasibility and clinical effect of cannulated screws plus separate vertical wirings technique for acute fracture of the inferior pole of the patella.Methods From May 2012 to September 2013,14 patients with fresh closed unilateral fracture of the inferior pole of the patella were treated with the cannulated screws plus separate vertical wirings.Eight patients were injured in traffic collisions and 6 in fall accidents.Fracture AO classification was type 34A1 in 8 patients and type 34A2 in 6 patients.Time from injury to operation was 1-7 days (mean,2.5 days).Number of tie wires was determined according to the degree of fracture comminution.Fracture healing,fixed position and patellar length were evaluated by radiographic examination postoperatively.Knee mobility and Bostman evaluation system were investigated to analyze the clinical effect.Results All the patients obtained average 15-month follow-up (range,12 to 29 months).At postoperative 2 months,the fracture healed with good alignment of the broken bone and proper place of the internal fixation device noted on the X-ray films.At postoperative 6 and 12 months,X-ray films revealed fracture bony healing,good location of the wire internal fixation,and no apparent shortening of the patella.At the 12 months,range of knee motion was (126.0 ± 4.5) ° for flexion and (2.0 ± 1.7) ° for extension.Bostman functional score for patella fracture was (28.1 ± 1.9) points.And 12 patients were rated as excellent and 2 good,with excellence rate of 100％.Conclusion Cannulated screw fixation plus separate vertical wiring is effective to stabilize patella inferior pole fracture and has good results,indicating a recommended surgical method.

Osteosíntesis con tornillos canulados en fracturas mediales de cadera. Factores pronósticos y resultados en 93 casos / Osteosynthesis of femoral neck fractures with cannulated screws. Prognostic factors and results in 93 cases

Introducción: La reducción y osteosíntesis con tornillos canulados en las fracturas mediales de cadera constituye una opción terapéutica válida. Nuestro objetivo es identificar factores pronósticos y grupos de riesgo. Materiales y Métodos: Se estudiaron retrospectivamente 93 fracturas intracapsulares de cadera tratadas con fijación interna con tornillos canulados de 6,5 mm, entre junio de 1995 y marzo de 2011 (71 no desplazadas y 22 desplazadas). Resultados: En 82 de los 93 casos, se observó la consolidación de la fractura. Once pacientes tuvieron complicaciones (5 seudoartrosis y 6 necrosis avascular). En el grupo de fracturas no desplazadas, la consolidación fue del 95,8 por ciento y, en el grupo de las desplazadas, del 63,6 por ciento. En este último grupo, si presentaban conminución, la consolidación fue del 50 por ciento y, en el grupo sin conminución, fue del 71,4 por ciento. El índice de consolidación fue del 46,1 por ciento con reducción cerrada y del 88 por ciento con reducción abierta. Conclusión: La reducción cerrada y la osteosíntesis con tornillos canulados en fracturas impactadas o no desplazadas del cuello del fémur, cualquiera sea la edad del paciente, resulta un método exitoso. En las fracturas desplazadas, en cambio, la consolidación sin necrosis es menos previsible, por lo que su indicación deberá ser más meditada.

Background: Reduction and osteosynthesis with cannulated screws in femoral neck fracture is a valid therapeutic option. Our objective is to identify prognostic factors and risk groups. Methods: We studied retrospectively 93 femoral neck fractures treated with internal fixation with cannulated screw between June 1995 and March 2011 (71 non-displaced and 22 displaced). Results: In 82 of the 93 cases we observed bone consolidation of the fracture. Eleven patients presented complications (5 non-union and 6 avascular necrosis). Consolidation rates were 95.8% and 63.6% in the non-displaced group and the displaced group of fractures. If the displaced fractures presented conminution, consolidation rate was 50% and 71.4% in the group without conminution. The consolidation index was 46.1% with closed reduction and 88% with open reduction. Conclusion: Closed reduction and internal fixation with cannulated screws in non-displaced femoral neck fractures, regardless of the patient’s age, is a successful method. In displaced fractures, on the other hand, necrosis free consolidation is less predictable, so its indication must be evaluated carefully.

Cannulated screws internal fixation plus three-column reconstruction for treatment of Lisfranc' s joint injuries / 中华创伤杂志

Objective To evaluate the preliminary outcome of cannulated screw internal fixation in treatment of the tarsometatarsal joint injuries.Methods From January 2005 to October 2010,21 patients(14 males and 7 females)with the tarsometatarsal joint injuries were treated.Their age ranged from 21 to 62 years(average 38.2 years).According to anatomical three-column classification,there were four patients with single medial column injury,four with medial and middle column injuries,three with middle and lateral column injuries,two with single lateral column injury and eight with three column injuries.The injury causes included traffic injury in nine patients,machine injury in eight and fall from height injury in four.The period from injury to admission was 2-15 hours(mean 5 hours).During operation,open reduction was performed,followed by internal fixation with the cannulated screw.X-ray examination was done in the regular follow-up and function was evaluated by using Maryland scoring system.Results Of all,19 patients were followed up for 4-47 months(mean 20 months),which showed no infection,loosing or breakage of the internal fixation.According to the Maryland scoring system,the clinical outcome was rated as excellent in eight patients,good in seven,fair in two and poor in two,with excellence rate of 79％.Conclusions The three-column theory plays an important role in clinical diagnosis and therapy of the tarsometatarsal joint injuries.Open reduction and cannulated screw internal fixation may attain satisfactory clinical results in treatment of the tarsometatarsal joint injuries.

Femoral Neck Fracture

The incidence of the femoral neck fracture is increasing, and the mechanism of the injuries is quite different in the young and elderly groups (high energy injury and osteoporosis, respectively). In the young group, early anatomical reduction and rigid fixation by such measures as multiple cannulated screws are mandatory to decrease the complications. In the elderly group, hip arthroplasty is recommended to decrease the complications due to early mobilization.

Arthroscopic Ankle Fusion Using Two Medial Cannulated Screws / 대한족부족관절학회지

PURPOSE: We evaluated the clinical and radiological results of arthroscopic ankle fusion using 2 medial screws which had advantages of less morbidity, early weight-bearing and high union rate. MATERIAL AND METHODS: From April, 2002 to March, 2004, 8 patients who had ankle osteoarthritis were treated by ankle fusion using 2 medial screws under arthroscopy; five patients with post-traumatic osteoarthritis, two with post-infectious arthritis and one with paralytic foot. There were 5 male and 3 female. Average age was 67 years old ranging from 57 to 71 years. We evaluated them clinically preoperative and postoperative using AOFAS score, VAS pain scale and patient's satisfaction. In regard to radiological fusion, we checked them by simple AP, lateral and mortise view. Follow up period was average 11 months (range, 6~24 months). RESULTS: All ankles were successfully fused with 2 medial screws under arthroscopy. The mean time of fusion was 10.5 weeks (range, 8~14 weeks). Patient's satisfaction checked at 6 months after operation had favorable results (excellent and good 75%). One case had pain on medial malleolar area because of screw's protrusion. CONCLUSION: Arthroscopic ankle fusion using 2 medial screws was good modality of ankle fusion with less morbidity and early weight-bearing in some cases of ankle arthritis.

The Treatment of Patellar Fracture with Modified Tension Band Wiring, using Cannulated Screws

PURPOSE: We have followed up the patients of the patellar fracture who had been treated with modified tension band wiring using cannulated screws. Since we have seen excellent clinical results, we would like to show the practical use of this operative method. MATERIALS AND METHODS: We analyzed the operation time, the time elapsed for union, and complications of 9 cases of the patellar fracture who were treated with this operative method at our hospital recently. RESULTS: Mean operation time (from the incision to the skin suture) was 68.3 min (40~120 min) and mean time elapsed for union was 9.7 weeks (8~12 wks). Mean time for full range of motion was 1 week in 5 cases of transverse fracture, 3 weeks (2~4 wks) in 3 cases of comminuted fracture. We found no complications like limitation of range of motion of the knee, loss of the reduction, irritation and migration of the hardware, and infection. CONCLUSION: This surgical technique provides stable fixation, allowes early motion excercise by minimizing injury to extensor mechanism and accompanies reduced rate of complications such as loss of the reduction, irritation or displacement of the hardware

An experimental study of cannulated screw fixation of femoral neck fractures aided by the bi-planar navigation robot system / 中华创伤骨科杂志

Objective To investigate clinical feasibility, security, and effects of cannulated screw fixation of femoral neck fractures aided by the bi-planar navigation robot system. Methods Under the guidance of the robot system which was developed jointly by Beijing Aeronautics and Space University and our hospital, 15 pins were inserted into the femoral necks of 5 Synbone models. The difference between the distance of any 2 points at the entry point and that at the outlet point was measured in the 5 cases. The ratio (P) of the difference to the length of the pin within the femoral neck of the Synbone models was calculated to evaluate how parallel the 2 pins were. The fluoroscopic times and the radiation exposure time in the robot-aided treatment were recorded and compared with those in the 12 cases of conventional operations which were conducted in our department from June to September, 2005. Results P was about 0.003 7 to 0.018 1, and the X-ray exposure time in robot aided system was 2.32 s vs 28.30 s in the conventional operations. The average fluoroscopic times in robot aided system were 4.4 vs 54.3 in the conventional operations. Conclusion As the bi-planar navigation robot system can provide accurate space orientation and stable navigation route, and can decrease the X-ray radiation to the patient and staff, it has a significant value in clinical application.

Cannulated Screw Fixation for Femoral Neck Fractures / 대한정형외과학회잡지

We reviewed retrospectively the results of stabilization of femoral neck fracture using multiple cannulated screws, in 20 patients who were treated at the department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital from January 1991 through July 1995. With the average follow up of 2 years (from 1 year to 4.5 years), we analyzed these patients with the adequacy of reduction by Garden's alignment index and the functional results of the hip by the Lunceford method. The mean age of patients was 70 years (ranged from 34 to 88 years). The types of fracture according to Garden's classification were fifteen cases of Garden stage I or II, and five cases of Garden stage III or IV. The average interval from injury to operation was four days, ranging from I to 14 days. The adequacy of reduction by Garden's alignment index were as follows: anatomic in 8, acceptable in 10 and poor in 2 cases. According to the Lunceford method, the functional results were as follows: excellent in II, good in 6, fair in 1 and poor in 2 cases, respectively. We found that good result out of the femoral neck fractures, especially for stage I and II with the anatomical and acceptable reduction, can be expected by multiple cannulated screw fixation and early ambulation as possible.