Browsing by Author "Ngo, Wayne"
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Item A review of musculoskeletal adaptations in individuals following major lower-limb amputation(Hylonome Publications, 2022-06-01) Finco, M. G.; Kim, Suhhyun; Ngo, Wayne; Menegaz, Rachel A.Structural musculoskeletal adaptations following amputation, such as bone mineral density (BMD) or muscle architecture, are often overlooked despite their established contributions to gait rehabilitation and the development of adverse secondary physical conditions. The purpose of this review is to provide a summary of the existing literature investigating musculoskeletal adaptations in individuals with major lower-limb amputations to inform clinical practice and provide directions for future research. Google Scholar, PubMed, and Scopus were searched for original peer-reviewed studies that included individuals with transtibial or transfemoral amputations. Summary data of twenty-seven articles indicated reduced BMD and increased muscle atrophy in amputees compared to controls, and in the amputated limb compared to intact and control limbs. Specifically, BMD was reduced in T-scores and Z-scores, femoral neck, and proximal tibia. Muscle atrophy was evidenced by decreased thigh cross-sectional area, decreased quadriceps thickness, and increased amounts of thigh fat. Overall, amputees have impaired musculoskeletal health. Future studies should include dysvascular etiologies to address their effects on musculoskeletal health and functional mobility. Moreover, clinicians can use these findings to screen increased risks of adverse sequelae such as fractures, osteopenia/porosis, and muscular atrophy, as well as target specific rehabilitation exercises to reduce these risks.Item Additive Effects of Diabetes and Lower-Limb Amputation on Osteoarthritis with Comparison to Diabetic and Healthy Controls(2022) Ngo, Wayne; Finnerty, Cait; Finco, MG; Holley, Bethany; Menegaz, Rachel A.Purpose: Individuals with type II diabetes and individuals with lower-limb amputation each have increased risks of developing osteoarthritis compared to the general population. Despite the high co-occurrence of type II diabetes with lower-limb amputations, the additive effects of these conditions are unclear. In order to better manage the risk of developing osteoarthritis in these populations, a better understanding of how diabetes and amputation might compound osteoarthritis risk is needed. Methods: We measured hip and knee joint space, as indicators of osteoarthritis, in four groups of individuals: 1) lower-limb amputees with diabetes, 2) lower-limb amputees without diabetes 3) diabetic controls, and 4) healthy controls. We hypothesized lower-limb amputees with diabetes would have the most impaired musculoskeletal health, followed by amputees without diabetes, diabetic controls, then healthy controls. 30 total CT scans of males (42-79 years; BMI 19.7 - 48.9 kg/m2) were obtained from the New Mexico Decedent Image Database. 10 scans were identified for amputees, diabetic controls, and healthy controls. Half of the lower-limb amputees had diabetes while half did not, to differentiate effects of diabetes and amputation on musculoskeletal health. 3D Slicer software was used to measure hip and knee joint spaces as indicators of osteoarthritis. Comparisons between groups were assessed using Kruskal-Wallis with Dunn's post hoc tests. Results: Amputees with and without diabetes showed significantly narrower hip (p=0.01) and knee (p=0.08) joint space bilaterally compared to diabetic and healthy controls. This result suggests amputees could be at a higher risk of developing lower-limb osteoarthritis compared to diabetic and healthy individuals, which is in line with prior work demonstrating the prevalence of osteoarthritis in the amputee population. Conclusions: In agreement with our hypothesis, box plots showed trends of amputees with diabetes having the most narrowed joint space, followed by amputees without diabetes, then diabetic controls, and healthy controls. While not statistically significant, these trends suggest amputees with diabetes are at increased risk of developing osteoarthritis compared to amputees without diabetes. Perhaps the aggressive management of blood glucose and post-amputation physiotherapy treatments could help reduce joint deterioration in these patients. Future work will focus on increasing sample size to assess if these findings are generalizable to a larger population. Increased risks of osteoarthritis can lead to pain, limited mobility, and decreased quality of life. This study can potentially inform clinical standards of care for patients with amputations. Earlier interventions such as proactive musculoskeletal screenings and targeted exercises may reduce risks of developing osteoarthritis, leading to improved clinical outcomes.Item Aggressive Fibromatosis of the Quadratus Lumborum in A 28-Year-Old-Female: A Case Report(2023) Gattu, Tejashwini; Ngo, Wayne; Martinez, Maria; Schultz, StevenBackground: Desmoid tumors (aggressive fibromatosis/desmoid-like tumors) are rare neoplasms that consist of proliferations of clonal fibroblastic proliferation that are aggressive and locally invasive. While the exact cause of desmoid tumors is unknown, they are associated with hereditary conditions such as Gardner’s syndrome and familial adenomatous polyposis both of which arise due to inactivating mutations of the APC gene. On the other hand, fibromatosis that arise sporadically generally has an activating mutation of the CTNNB1 gene which encodes beta-catenin. A history of trauma such as injuries and previous surgeries has also been associated with the development of desmoid tumors. Desmoid tumors are rare with an estimated incidence of 2-4 per million people per year and make up 0.03% of all neoplasms. Early diagnosis and treatment of desmoid tumors are crucial in minimizing morbidity and mortality. Fibromatosis primarily arise in the extra-abdominal setting which comprises approximately 58% of all cases. Among this, most arise in the shoulder or pelvic girdle region. Here, we report an uncommon site of origin for desmoid tumors. Case Presentation: A 28-year-old female with no previous history of trauma presented with lower back pain with radiculopathy radiating to her right hip. An MRI of the lumbar spine revealed a mass in the right iliac fossa and an abdominal and pelvic MRI showed a large circumscribed posterolateral right intra-abdominal wall mass extending up from the right iliac fossa with low signal bands on T1W and T2W imaging. There were intermediate signal areas elsewhere with islands of enhancement. Subsequent abdominal and pelvis CT showed a right posterior pelvic mass measuring 19x13x10 cm concerning for a neoplasm with fibrotic components. The mass originated from the right quadratus lumborum muscle. It involved the posterior distal transversus abdominis and internal oblique abdominal muscle anteriorly. Distally, it involved the iliacus muscle. Differential diagnoses were abdominal wall aggressive fibromatosis/desmoid tumor, solitary fibroid tumor, sarcoma, unusual GIST tumor, neuroectodermal tumor versus nerve sheath tumor, metastasis, lymphoma. A biopsy was performed and results were consistent with aggressive fibromatosis. Conclusion: Desmoid tumors are rare tumors with a locally aggressive and variable course and high risk of local recurrence. The diagnostic workup often includes imaging with MRI and CT and which allows for determining the origin and involvement of adjacent structures to guide possible interventions. Diagnosis can only be confirmed through biopsy which will reveal a monoclonal proliferation of fibroblasts. Treatment ranges from observation, radiotherapy, surgery, and various medications. Because this case presents a desmoid tumor originating from an uncommon site of origin in the quadratus lumborum region, we hope to provide a better clinical picture for the screening and diagnosis of similar aggressive fibromatosis.Item A Cross-sectional Study on Healthcare Barriers Experienced by WellMed Patients at the University of North Texas Health Science Center Geriatric Clinic(2023) Martinez, Maria Francesca Ysabelle; Ngo, Wayne; Garfield, TysonWellMed is Medicare advantage plan geared towards helping aging patients receive high quality healthcare at low cost. WellMed is available to Medicare eligible patients and dual eligible Medicare/Medicaid in Texas or Florida, with the University of North Texas Health Science Center (UNTHSC) geriatric clinic being one of the few centers in the area accepting the insurance. During the pandemic, it has become clear that access to care is a barrier for aging and underinsured patients, and a better understanding of what the barriers these patients face will help facilitate improved quality of care. A cross-sectional survey using Qualtrics was administered to WellMed patients at the UNTHSC geriatric clinic during regular clinic hours from June-July 2022. A total of 36 in-person surveys were administered and completed. The self-reported survey consisted of 23 multiple choice and fill-in questions that elicited information on wellness and potential healthcare barriers. A comparison between each variable and patient zip code was made. Looking at the responses to patient perceived healthcare barriers, 59.4% of respondents reported no barriers, 21.2% stated location of clinic, 12.1% lacked transportation, 12.1% found the appointment system difficult to use, and 6.1% had inadequate finances. Of note, incompatible clinical hours and lack of support for languages other than English were not perceived as barriers. For the fill-in "other barriers not listed” option, 5.6% stated the telephone system not being adequate for communication to the staff and doctors, and 2.8% cited problems with the patient portal. A total of 24 different zip codes were collected. When correlating each barrier with zip code, clinic location and lack of transport correlated with areas on the edge of Tarrant County. No particular relationship between zip code and other outcome measures were observed. Access to care is a social determinant of health that is cited as a cause of decreased health outcomes. In Tarrant County 22% of adults are uninsured and the ratio of primary care physicians to patients is 1:1690. This study elucidates health barriers WellMed patients in the county are facing. Addressing these barriers patients can experience improved quality of healthcare and easier access to necessary care.Item Evaluating a Nail-Plate Combination Implant in Treatment of Distal Femoral Fractures: A Case Series(2023) Ngo, Wayne; Dutta, Arpam; Benage, TimothyDistal femur fractures are severe injuries that have varying management among orthopedic surgeons. These fractures are thought to be caused by high-energy trauma in younger patients and low-energy injuries in older patients. These fractures account for approximately 6 to 7% of all fractures and the gender distribution is estimated to be 33.4% male and 66.6% female. Additionally, there is increase in distal femoral fracture incidence after the age of 60 in both genders. Therefore, these fractures require optimal treatment to prevent disability and improve patient quality of life. Current treatment for distal femur fractures can vary broadly but in this study, we focus on intramedullary nailing and plating. Intramedullary nailing has been championed as less invasive as it offers minimal disruption of soft tissues and endosteal arterial supply. Nailing of extremely distal periarticular fractures is becoming more common because of better load sharing and minimal soft tissue stripping compared to plating. In comparison, submuscular locking plates have become standard in these fractures and offer several advantages. These include more flexibility in periprosthetic fractures, preservation of blood supply to the periosteum, decreased time under anesthesia, and lower blood loss. The purpose of this case series is to qualitatively examine the outcomes of patients who received a nail-plate combination for their distal femoral fracture. A chart review of 10 patients who received a nail and side plate combination at JPS Hospital was conducted. These patients underwent surgery from August 2021 to May 2022. They consisted of 4 males and 6 females with a mean age of 63 years (range of 36 to 89 years). For each patient, an outcome of union or nonunion was recorded along with time since surgery. The nailing system used was the Synthes Retrograde Femoral Nailing System. When examining results, only 6 patients had follow up visits. 4 of the 6 patients achieved union at times of 3, 4, 6, and 8 months since date of surgery. Meanwhile, the remaining 2 patients had nonunion. One of these nonunion patients required hardware removal and has not achieved union at 5 months. The other nonunion patient has yet to achieve union at 7 months. When compared to current literature, two studies have shown promising results with the nail-plate combination. The first had 8 patients with 100% union rate while the second had 15 patients with 93% union rate. The union rate in this study is relatively lower at 66%. However, this can be attributed to variables such as severity of initial injury, patient compliance, comorbidities affecting healing, and implant manufacturer. The rationale behind the combination technique is creating a stable and balanced fixation that allows for immediate weight bearing and mobilization post-surgery. While it shows promising results, more research in larger cohorts need to be done before the nail-plate combination can be evaluated against traditional methods.Item Indications of musculoskeletal health in deceased male individuals with lower-limb amputations: comparison to non-amputee and diabetic controls(Springer Nature, 2023-06-01) Finco, M. G.; Finnerty, Caitlyn; Ngo, Wayne; Menegaz, Rachel A.Individuals with lower-limb amputations, many of whom have type 2 diabetes, experience impaired musculoskeletal health. This study: (1) compared residual and intact limbs of diabetic and non-diabetic post-mortem individuals with amputation to identify structures vulnerable to injury, and (2) compared findings to diabetic and healthy control groups to differentiate influences of amputation and diabetes on musculoskeletal health. Postmortem CT scans of three groups, ten individuals each, were included: (1) individuals with transtibial or transfemoral amputations, half with diabetes (2) diabetic controls, and (3) healthy controls. Hip and knee joint spaces, cross-sectional thigh muscle and fat areas, and cross-sectional bone properties (e.g. area, thickness, geometry) were measured. Wilcoxon Signed-Rank and Kruskal-Wallis tests assessed statistical significance. Asymmetry percentages between limbs assessed clinical significance. Residual limbs of individuals with amputation, particularly those with diabetes, had significantly less thigh muscle area and thinner distal femoral cortical bone compared to intact limbs. Compared to control groups, individuals with amputation had significantly narrower joint spaces, less thigh muscle area bilaterally, and thinner proximal femoral cortical bone in the residual limb. Diabetic individuals with amputation had the most clinically significant asymmetry. Findings tended to align with those of living individuals. However, lack of available medical information and small sample sizes reduced the anticipated clinical utility. Larger sample sizes of living individuals are needed to assess generalizability of findings. Quantifying musculoskeletal properties and differentiating influences of amputation and diabetes could eventually help direct rehabilitation techniques.Item Musculoskeletal Differences Between Amputated and Non-Amputated Lower Limbs(2022) Finco, MG; Finnerty, Cait; Ngo, Wayne; Holley, Bethany; Menegaz, Rachel A.Purpose: People with lower limb amputations frequently experience greater risks of musculoskeletal injury. Forces active during walking help to develop and maintain the shape, volume, and strength of musculoskeletal tissues. Conversely, altered walking patterns following limb loss may lead to atrophy of muscle and bone tissues. Reductions in joint spaces are indicative of excess stress placed on the limb, which may lead to osteoarthritis. Bone loss in high stress regions like the femoral neck can reduce the bone's ability to resist compressive or rotational movements, making the bone more susceptible to fracture. The aim of this study was to measure musculoskeletal differences between an individual's residual (amputated) limb and intact (non-amputated) limb to identify structures vulnerable to injury. We hypothesized that the residual limb, compared to the intact limb, would show: 1) less muscle mass and more fat as indicators of muscle atrophy, 2) wider hip and knee joint spaces as indicators of osteoarthritis in the intact limb, and 3) decreased femoral neck width as an indicator of fracture risk. Methods: CT scans of 10 males (42-79 years) were obtained from the New Mexico Decedent Image Database. 3D Slicer software was used to measure gross skeletal properties, hip and knee joint dimensions, and cross-sectional muscle and fat tissue areas at the midshaft. A Wilcoxon Signed-Rank test was used to assess the differences between residual and intact limbs. The significance level was set at α ≤ 0.10 due to a small sample size. Results: Compared to the intact limb, the residual limb had significantly less muscle tissue area (p=0.010) and a significantly narrower femoral neck width (p=0.077). No significant differences were found in hip or knee joint spaces between limbs. Conclusions: In agreement with hypotheses 1 and 3, these results suggest residual limbs are at increased risk of muscle atrophy and femoral neck fracture compared to intact limbs. Loading inequalities between the residual and intact limb likely contribute to these results. A better understanding of the structural properties associated with musculoskeletal atrophy could inform targeted therapies to reduce the likelihood of injury in this population. Future studies will assess biomechanical properties, such as moment of inertia, to better understand the residual limb's ability to withstand torsional forces and fracture. Additional data on how musculoskeletal tissues respond to unloading at multiple structural levels can improve clinical interventions for lower limb strength and function in amputees.Item Optimal DVT Prophylaxis in Patients with Traumatic Hip Fracture: A Literature Review(2024-03-21) Meyer, Adam; Craddock, Germain; Park, Amber; Oesterreich, Chloe; Barba, Estefania; Ngo, Wayne; Araiza, EdgarIntroduction: Hip-fracture patients face elevated life-threatening complications, including VTE and DVT. National guidelines recommend thromboprophylaxic agents such as LMWH, fondaparinux, apixaban, and warfarin. This review aims to summarize the literature investigating DVT prophylaxis in traumatic hip fracture repair, aiding healthcare professionals in clinical enhancement and agent selection. Methods: This review searched peer-reviewed articles in PubMed, Google Scholar, and Scopus. Agents considered for DVT prophylaxis included LMWH, UFH, fondaparinux, DOACs, warfarin, and aspirin. Discussion: The summary data of 9 articles suggest varying preferences for thromboprophylaxis amongst physicians managing hip fractures. LWMH is often administered subcutaneously with relatively common complications and efficient prevention of VTEs. However, due to inconvenient parenteral administration and high administration costs, low patient compliance poses a barrier. Direct Xa inhibitors, like apixaban and DOACs, have gained prominence due to easy administration, robust VTE prevention, and cost efficiency. These agents versus Lovenox yield mixed conclusions, some suggesting similar efficacy and higher incidences of hemorrhage. Fondaparinux, a synthetic anticoagulant, presents merits in VTE prevention, including a single subcutaneous injection, no need for lab monitoring, and no risk of heparin-induced thrombocytopenia. Some studies suggest fondaparinux is more effective than LWMH in preventing VTE but has a slightly higher risk of bleeding. Warfarin, a well-established anticoagulant, boasts high efficacy and safety but requires frequent lab monitoring, interacts with medications, and may lead to surgery delays. Aspirin, a widely available antiplatelet drug, is typically taken orally as a low-dose pill. Aspirin provides clinical benefits in VTE prophylaxis and becomes more appealing when considering its lower cost and decreased risks of bleeding. Conclusion: This review summarizes viable agents for VTE prevention in traumatic hip fractures. Future studies should explore how socioeconomic factors and patient health literacy impact drug adherence and efficacy. Clinicians can use this knowledge to improve outcomes in this vulnerable population.Item Optimizing Chronic Pain Management through Patient Engagement with Health-Related Quality-of-Life Measures: A Randomized Controlled Trial(2022) McDonald, Hanna; Yablon, Mckenna; Ngo, Wayne; Garza, Kimberly; Licciardone, John C.Purpose Chronic low back pain (CLBP) is a common health issue that requires accessible and cost-effective methods of management. Relevant guidelines in the United States emphasize the use of non-pharmacological and non-opioid treatments as first-line interventions. Additionally, health-related quality of life (HRQOL) has been proposed as an emerging measure of CLBP outcomes that may provide important information not captured by conventional measures such as pain intensity or physical function. Recent studies suggest that eHealth interventions to promote patient self-management may improve health outcomes in patients with chronic pain, including low back pain. The primary aim of this randomized controlled trial was to measure the efficacy of an eHealth intervention for HRQOL outcomes in patients with CLBP. Methods Trial participants were recruited from the PRECISION Pain Research Registry from November 2019 through February 2021. These participants met the NIH definition of CLBP, were between 21-79 years of age, and had HRQOL deficits involving sleep disturbance, pain interference, anxiety, depression, and low energy or fatigue (SPADE cluster derived from the Patient-Reported Outcomes Measurement Information System) as evidenced by a baseline score ≥55. A total of 331 participants were randomized to treatment or wait-list control groups. The treatment group received an eHealth intervention, which consisted of an individualized HRQOL report based on the SPADE cluster and subscale scores and an interpretation guide. Outcomes were assessed 3 months after randomization. The primary outcomes were changes in the SPADE cluster and subscale scores. Secondary outcomes included low back pain intensity measured with a numerical rating scale, and back-related disability measured with the Roland-Morris Disability Questionnaire. Changes over time for each outcome measure reported by participants in each group were compared using the Student's t test for statistical significance and Cohen's d statistic for clinical importance. Positive change scores and d-statistics favored the eHealth intervention group. Results There were no significant differences between the eHealth intervention and wait-list control groups for changes over time in any primary or secondary outcome measure. The mean difference between groups in change scores on the SPADE cluster was 0.15 (95% CI, -0.73 to 1.03) (P=0.73). The d statistic for this difference was 0.04 (95% CI, -0.18 to 0.25). The corresponding d statistics for the SPADE subscales ranged from -0.06 (95% CI, -0.27 to 0.16) for anxiety to 0.11 (95% CI, -0.10 to 0.33) for sleep disturbance. Conclusions The eHealth intervention studied herein did not achieve statistically significant or clinically important improvements in any of the primary or secondary outcome measures. However, almost three-fourths of participants were enrolled after onset of the COVID-19 pandemic and may have had limited access to treatments for low back pain or to facilities or services needed to act on the information or recommendations derived from the HRQOL report. Thus, the validity and generalizability the findings may have been limited by the unforeseen onset and impact of the COVID-19 pandemic shortly after beginning the trial.Item A Rare Case of Paraumbilical Hernia Containing and Obstructing the Stomach(2024-03-21) Martinez, Maria Francesca Ysabelle; Prado, Cynthia; Cao, Ngan; Ngo, Wayne; Salinas, Miguel; Maheshwari, MukulBackground: Abdominal hernias occur when peritoneal lined organs protrude through the abdominal wall. They are common with an estimated prevalence of 25% in adults. Patients may be asymptomatic but surgical intervention may be advised if patients are at risk for complications such as incarceration and strangulation. Initial diagnosis of abdominal hernias is made clinically but may be assisted with imaging. Computed tomography (CT) is the current modality of choice. In this case report, we specifically focus on midline abdominal hernias. These include epigastric, paraumbilical, umbilical, and hypogastric hernias. The most frequent abdominal hernia is the paraumbilical/umbilical hernia which account for 13.9% of all hernias. These occur due to weakness or defect in the linea alba and/or abdominal rectus muscles. Patient presentation varies but many have a visible bulge that may or may not be tender to palpation. Typical contents of paraumbilical/umbilical hernias include peritoneal fat, omentum, small bowel, and large bowel. We present a unique case of stomach herniation into a pre-existing ventral abdominal hernia that has been described only a few times in the last century. Identification with CT allowed for appropriate anatomical resolution to assess for bowel obstruction and strangulation of hernia contents. Case Presentation: A 72-year-old female presented to the emergency department with abdominal pain, nausea, and emesis. Prior computed tomography (CT) studies completed one month before presentation showed a large, ventral abdominal paraumbilical hernia without obstruction or strangulation. However, one month later she presented with worsening symptoms of abdominal pain, nausea, and emesis. Repeat abdominal and pelvis CT showed interval herniation of the distal stomach and proximal bowel into the patient’s known paraumbilical hernia. This resulted in gastric outlet obstruction. Immediate management included intravenous fluids, nasogastric tube placement and surgical correction. Operative report revealed a large ventral abdominal hernia with viable stomach, proximal duodenum (D1), cecum, ascending and transverse colon, and multiple loops of small bowel without evidence of strangulation. The patient successfully recovered after surgery. Conclusion: A rare complication in paraumbilical/umbilical hernias is gastric herniation into an existing hernia. Patients may present with red flag symptoms such as abdominal pain, nausea, and emesis. Quick identification of these symptoms and rapid visualization with CT will help identify the extent of herniation and other complications such as bowel obstruction, strangulation, and incarceration. A major risk factor for gastric herniation is weakened abdominal muscles and increased laxity of stomach ligaments found in populations such as multiparous women of middle to late ages. Healthcare professionals should be aware of patients who fit this demographic to educate them on the risk of herniation and recommend them for prophylactic surgical treatment.Item Tibial Plateau Fracture Treated with ORIF and Tibia Strut in a 37-year-old Male: A Case Report(2023) Ngo, Wayne; Craddock, Germain; Frangenberg, AlexanderTibial plateau fractures (TPFs) are orthopedic challenges that have multiple injury modalities and clinical presentations. These fractures can be caused by high energy or low energy trauma. Epidemiological studies estimate peak incidence in the third and sixth decade of life for males and between the fourth and fifth decade for females. TPFs are often classified using the Schatzker classification system which can dictate management. Case presentation: this is a 37-year-old male who complained of right knee pain after sustaining a fall from a truck ramp. The patient heard a pop and had severe, sharp pain in his right knee. In the emergency room, CT imaging demonstrated a comminuted tibial plateau fracture involving the medial and lateral tibial plateau as well as the metaphysis. The lateral tibial plateau was depressed by 5 mm. The patient was placed in a knee immobilizer, made non-weight bearing, and scheduled for surgical planning in 2 weeks. Unfortunately, the patient never followed up and opted for non-operative management. 6 months later, he came to our clinic because of significant pain and instability in the knee. X-rays demonstrated a chronic, incompletely healed fracture of the medial tibial metaphysis extending to the tibial eminence. Chronic fracture deformities of the medial femoral condyle and lateral tibial plateau were also observed. The patient agreed to surgery at our clinic. The surgical technique was a proximal tibial osteotomy. An incision was made centered over the medial aspect of the gastrocnemius. The medial soft tissue sleeve was elevated off the proximal tibia in subperiosteal fashion while maintaining the MCL insertions. Next, a sagittal saw was used to make an osteotomy. The proximal tibia was elevated to correct for varus deformity. Afterwards, a fibula strut was placed followed by plate and screws. After biplanar x-ray verified adequate reduction and hardware replacement, bone filler was used to fill the void. Post operatively, the patient was made non-weight bearing for 3 months. Range of the motion was encouraged as tolerated. At the first month follow up, the patient’s pain was well controlled and range of motion exercises were done regularly. No paresthesia, numbness, or wound dehiscence were noted. Repeat x-rays demonstrated intact hardware with evidence of healing fracture lines compared to immediate post-operative images. Fragments and the knee were appropriately aligned. No significant soft tissue or joint effusion were appreciated on imaging. Conclusion: after failing nonoperative treatment, this patient with comminuted bicondylar tibial plateau fracture has received definitive treatment with open reduction and internal fixation. Higher rates of unacceptable results from nonoperative treatment is inline with Schatzker’s series in which operative treatment resulted in more acceptable outcomes. Because the fracture in this patient is more consistent with a Schatzker IV or V classification with intra-articular displacement more than 2 mm, the patient’s choice for nonoperative treatment was not appropriate. This led to a malunion and non-union that necessitated surgery. Perhaps greater warning should have been given to the patient about the risks of nonoperative treatment at their initial encounter.