Early Weight-bearing Rehabilitation Research Articles

Early versus delayed weight-bearing following operatively treated ankle fracture (WAX): a non-inferiority, multicentre, randomised controlled trial

After surgery for a broken ankle, patients are usually instructed to avoid walking for 6 weeks (delayed weight-bearing). Walking 2 weeks after surgery (early weight-bearing) might be a safe and preferable rehabilitation strategy. This study aimed to determine the clinical and cost effectiveness of an early weight-bearing strategy compared with a delayed weight-bearing strategy. This was a pragmatic, multicentre, randomised, non-inferiority trial including 561 participants (aged ≥18 years) who received acute surgery for an unstable ankle fracture in 23 UK National Health Service (NHS) hospitals who were assigned to either a delayed weight-bearing (n=280) or an early weight-bearing rehabilitation strategy (n=281). Patients treated with a hindfoot nail, those who did not have protective ankle sensation (eg, peripheral neuropathy), did not have the capacity to consent, or did not have the ability to adhere to trial procedures were excluded. Neither participants nor clinicians were masked to the treatment. The primary outcome was ankle function measured using the Olerud and Molander Ankle Score (OMAS) at 4 months after randomisation, in the per-protocol population. The pre-specified non-inferiority OMAS margin was -6 points and superiority testing was included in the intention-to-treat population in the event of non-inferiority. The trial was prospectively registered with ISRCTN Registry, ISRCTN12883981, and the trial is closed to new participants. Primary outcome data were collected from 480 (86%) of 561 participants. Recruitment was conducted between Jan 13, 2020, and Oct 29, 2021. At 4 months after randomisation, the mean OMAS score was 65·9 in the early weight-bearing and 61·2 in the delayed weight-bearing group and adjusted mean difference was 4·47 (95% CI 0·58 to 8·37, p=0·024; superiority testing adjusted difference 4·42, 95% CI 0·53 to 8·32, p=0·026) in favour of early weight-bearing. 46 (16%) participants in the early weight-bearing group and 39 (14%) in the delayed weight-bearing group had one or more complications (adjusted odds ratio 1·18, 95% CI 0·80 to 1·75, p=0·40). The mean costs from the perspective of the NHS and personal social services in the early and delayed weight-bearing groups were £725 and £785, respectively (mean difference -£60 [95% CI -342 to 232]). The probability that early weight-bearing is cost-effective exceeded 80%. An early weight-bearing strategy was found to be clinically non-inferior and highly likely to be cost-effective compared with the current standard of care (delayed weight-bearing). National Institute for Health and Care Research (NIHR), NIHR Barts Biomedical Research Centre, and NIHR Applied Research Collaboration Oxford and Thames Valley.

Early Weight-bearing Rehabilitation Protocol After Anterior Cruciate Ligament Reconstruction.

Anterior cruciate ligament (ACL) injury is one of the common sports injuries. Anterior cruciate ligament reconstruction (ACLR) is the mainstream treatment for ACL injury, aiming to regain normal anatomical structure and stability of the knee joint and promote the patient's return to sports. Under the guidance of the concept of enhanced recovery after surgery, early weight-bearing rehabilitation (EWB) is an important factor affecting patient function and quality of life. However, there is no consensus on whether EWB rehabilitation can be performed after ACL surgery. This study aims to explore the safety and feasibility of EWB after ACL surgery. The study implemented a gradual EWB rehabilitation program in the experimental group, including weight-shifting training, balance training, and gait training on the affected lower limb, and assessed wound healing and stability of the knee joint. The study found that EWB after ACLR is safe and feasible. EWB rehabilitation not only does not pose a negative effect on the patient's knee pain, swelling, wound healing, and stability, but also helps to improve knee active flexion and quality of life faster and better. The EWB program in this study is simple, safe, and effective, and it provides strong theoretical guidance and practical demonstration for accelerated rehabilitation after ACLR.

Reparación percutánea del tendón de Aquiles con sutura reabsorbible: resultados y complicaciones

ObjectiveThe purpose of this study is to evaluate the clinical outcomes and complications of percutaneous achilles tendon repair with absorbable sutures. Material and methodsA prospective cohort study including patients treated for an achilles tendon rupture from January 2016 to March 2019 was conducted. Inclusion criteria≥18 years of age, non-insertional (2–8cm proximal to insertion) achilles tendon ruptures. Open or partial ruptures were excluded. The diagnosis was based on clinical criteria and confirmed by ultrasonography in all patients. Epidemiological data, rupture and healing risk factors, previous diagnosis of tendinopathy, pre-rupture sport activity, job information, mechanism of rupture and the time in days between lesion and surgery were collected.Patients were assessed using visual analogue scale at the 1, 3, 6 and 12-month follow-up. The achilles tendon rupture score were assessed at the 6 and 12 month follow-up. Ultrasound was performed at the 6-month follow-up. The re-rupture rate and postoperative complications were also collected. ConclusionsIn our experience, percutaneous achilles tendon repair with absorbable sutures in patients with an acute achilles tendon rupture has shown good functional results but with a high incidence of complications. Although most complications were transitory sural nerve symptoms, this complication would be avoided in patients treated conservatively. For this reason, conservative treatment associated with an early weightbearing rehabilitation protocol should be considered a viable option for patients with achilles tendon ruptures, mainly in cooperative young patients.

Artículo traducido] Reparación percutánea del tendón de Aquiles con sutura reabsorbible: resultados y complicaciones

Background and objectiveThe purpose of this study is to evaluate the clinical outcomes and complications of percutaneous Achilles tendon repair with absorbable sutures. Material and methodsProspective cohort study including 52 patients treated for Achilles tendon ruptures (January 2016 to March 2019). Inclusion criteria≥18 years of age, non-insertional Achilles tendon ruptures. Diagnosis based on clinical criteria, confirmed by ultrasonography. Assessment using Visual Analogue Scale (VAS), Achilles Tendon Rupture Score (ATRS) and ultrasound. Re-rupture rate and postoperative complications were collected. ResultsVAS scoring (SD) at 1, 3, 6 and 12 months follow-up (FU) were 2.63 (0.83), 1.79 (1.25), 0.69 (1.09) and 0.08 (0.39), respectively. Mean (SD) ATRS score was 92.45 points at 6 months (6.27) and 94.04 points at 12 months FU (4.59). Three re-ruptures (5.77%) occurred with a mean time between surgery and re-rupture of 108.75 days (SD 28.4), all of them within 4-month FU. No ruptures at the time to return to sports activity. Thirteen complications (25%) (3 re-ruptures, 1 superficial wound infection and 9 transitory sural nerve injuries). ConclusionsPercutaneous Achilles tendon repair with absorbable sutures in patients with acute Achilles tendon ruptures has shown good functional results but with a high incidence of complications. Although most complications were transitory sural nerve symptoms, these would be avoided with conservative treatment. Conservative treatment associated with an early weight-bearing rehabilitation protocol should be considered a viable option for patients with Achilles tendon ruptures, specially in cooperative young patients.

Percutaneous achilles tendon repair with absorbable suture: Outcomes and complications

ObjectiveThe purpose of this study is to evaluate the clinical outcomes and complications of percutaneous achilles tendon repair with absorbable sutures. Material and methodsA prospective cohort study including patients treated for an achilles tendon rupture from January 2016 to March 2019 was conducted. Inclusion criteria≥18 years of age, non-insertional (2–8cm proximal to insertion) achilles tendon ruptures. Open or partial ruptures were excluded. The diagnosis was based on clinical criteria and confirmed by ultrasonography in all patients. Epidemiological data, rupture and healing risk factors, previous diagnosis of tendinopathy, pre-rupture sport activity, job information, mechanism of rupture and the time in days between lesion and surgery were collected.Patients were assessed using visual analogue scale (VAS) at the 1, 3, 6 and 12-month follow-up. The achilles tendon rupture score (ATRS) were assessed at the 6 and 12 month follow-up. Ultrasound was performed at the 6-month follow-up. The re-rupture rate and postoperative complications were also collected. ConclusionsIn our experience, percutaneous achilles tendon repair with absorbable sutures in patients with an acute achilles tendon rupture has shown good functional results but with a high incidence of complications. Although most complications were transitory sural nerve symptoms, this complication would be avoided in patients treated conservatively. For this reason, conservative treatment associated with an early weightbearing rehabilitation protocol should be considered a viable option for patients with achilles tendon ruptures, mainly in cooperative young patients.

Percutaneous Achilles tendon repair with absorbable suture: Outcomes and complications

Background and objectiveThe purpose of this study is to evaluate the clinical outcomes and complications of percutaneous Achilles tendon repair with absorbable sutures. Material and methodsProspective cohort study including 52 patients treated for Achilles tendon ruptures (January 2016 to March 2019).Inclusion criteria: ≥18 years of age, non-insertional Achilles tendon ruptures. Diagnosis based on clinical criteria, confirmed by ultrasonography.Assessment using Visual Analogue Scale (VAS), Achilles Tendon Rupture Score (ATRS) and ultrasound. Re-rupture rate and postoperative complications were collected. ResultsVAS scoring (SD) at 1, 3, 6 and 12 months follow-up (FU) were 2.63 (0.83), 1.79 (1.25), 0.69 (1.09) and 0.08 (0.39), respectively. Mean (SD) ATRS score was 92.45 points at 6 months (6.27) and 94.04 points at 12 months FU (4.59). Three re-ruptures (5.77%) occurred with a mean time between surgery and re-rupture of 108.75 days (SD 28.4), all of them within 4-month FU. No ruptures at the time to return to sports activity. Thirteen complications (25%) (3 re-ruptures, 1 superficial wound infection and 9 transitory sural nerve injuries). ConclusionsPercutaneous Achilles tendon repair with absorbable sutures in patients with acute Achilles tendon ruptures has shown good functional results but with a high incidence of complications. Although most complications were transitory sural nerve symptoms, these would be avoided with conservative treatment. Conservative treatment associated with an early weight-bearing rehabilitation protocol should be considered a viable option for patients with Achilles tendon ruptures, specially in cooperative young patients.

Exploring effects of cryotherapy modalities on pain, muscle strength and joint position sense in healthy participants with induced knee pain

Keywords: Cryotherapy; Compression; Rehabilitation Purpose: In the current guidelines for acute injury management ‘optimal loading’ has been introduced to facilitate early activity to optimise recovery. Although studies have identified potential adverse effects on muscle performance and knee joint repositioning following ice, evidence supports the use of cryotherapy to provide short-term pain relief. Cryotherapy interventions which can provide short-term pain relief, yet minimise adverse effects, would allow early activity with a lower risk of injury. This study utilised a targeted compressive-cryotherapy approach on experimentally induced knee pain in healthy participants and explored the effects on muscle strength and joint position sense. Methods: 10 healthy participants (7 females, 3 males; 32.9 ± 11.6 years) were induced with experimental knee pain using capsaicin cream (0.075%). Topical capsaicin is a common experimental pain method and was applied to the participant's skin on the medial aspect of the non-dominant knee. A randomised crossover design was adopted, exploring two 20-minute cryotherapy interventions, (1) ice (wetted: 400 g cubed ice, 400 ml water) and (2) Swellaway (10 °C, 50 mmHg compression), during separate testing sessions. Four outcome measures were explored: (i) participant-reported numerical pain rating scale (NPRS), (ii) pressure pain threshold (PPT), (iii) quadriceps muscle strength and (iv) joint position sense (JPS). These outcomes were recorded at four time points: pre-capsaicin cream application (T1), post-capsaicin (T2), post-cooling intervention (T3) and 20-minutes post-cooling (T4). Repeated measures ANOVAs (3 × 2) with post-hoc pairwise comparisons were used to assess change in outcomes between time points. Results: Complete pain relief (≥93% pain reduction) was achieved immediately post-cooling in 7 participants for Swellaway and in 4 participants for ice. Participant NPRS was reduced by 100% (Swellaway) and 91% (ice) 20-minutes post-cooling. No statistically significant differences were found in short-term pain relief between interventions. Significant increases in PPT were found between post-capsaicin and post-cooling (27% increase) and between post-capsaicin and 20-minutes post-cooling (20% increase) following Swellaway. No significant differences were found in PPT between any time points following ice. Ice reduced quadriceps strength by 13% immediately post-cooling. Swellaway had a negligible effect on muscle strength immediately post-cooling (+0.3%). The strength deficit post ice was almost double the percentage reduction (6%) associated with clinically important functional deficits in people with knee osteoarthritis. Significant increases were found in range of motion (ROM) in the coronal plane following ice, which indicates increased instability (adduction/abduction). Despite not being statistically significant, a trend of increased instability (14%) in the transverse plane ROM 20-minutes post-cooling was most apparent following the ice (P = 0.053). Conclusion(s): Targeted compressive-cryotherapy has the potential to achieve short-term pain relief, as demonstrated on healthy participants with experimentally induced knee pain. The results suggest a targeted approach can also minimise the negative effects on muscle strength, dynamic stability and knee joint repositioning, which may traditionally have discouraged early optimal loading post cryotherapy. This would allow individuals to return to weight-bearing rehabilitation exercises earlier, at a lower risk of re-injury post-intervention. Impact: Clinicians could consider utilising targeted compressive-cryotherapy to provide a short-term pain relief and minimise the reported adverse effects following cryotherapy, facilitating early weight-bearing rehabilitation. Funding acknowledgements: This research was carried out as part of a Knowledge Transfer Partnership between Manchester Metropolitan University, University of Central Lancashire and Swellaway.

Biomechanical analysis of minimally invasive crossing screw fixation for calcaneal fractures: Implications to early weight-bearing rehabilitation

BackgroundMinimally invasive fixation using crossing screws was believed to produce satisfactory clinical outcome whereas its stability in early weight-bearing remained controversial. This study aimed to analyze the biomechanical stability of minimally invasive fixation during balanced standing and walking stance, and provide evidence for early rehabilitation. MethodsA finite element model of foot-ankle-shank complex was reconstructed based on computed tomography and magnetic resonance images, and validated by plantar pressure of the model participant. A Sanders III calcaneal fracture was created on the model, and then fixed using crossing screws. The predicted stress distribution, fracture displacement, Bohler's angle and Gissane's angle were compared between the intact calcaneus and fracture model with the fixation. FindingsPostoperatively, the concentrated stress appeared at the junction of the calcaneus and its surrounding tissues (especially Achilles tendon, plantar fascia and ligaments) during standing and walking stances, and the stress exceeded the yield strength of trabecular bone. The longitudinal screws sustained the highest stresses and concentrated at the tips and the calcaneal tuberosity junction. The displacement of posterior joint facet, Bohler's angle, and Gissane's angle were within the acceptable range either standing or walking after the fixation. InterpretationEarly weight-bearing standing and walking after minimally invasive fixation may cause high stress concentration thereby induce calcaneus stress fractures and other complications like plantar fasciitis and heel pain, so it should not be supported. The peri-calcaneus tendons, i.e., Achilles tendon and plantar fascia, play key roles in the stabilization of the calcaneal fracture after operation.

Use of Ultrasonically Interdigitated Anchors in Haglund's Deformity Correction Surgery.

Haglund's deformity is a common cause of foot pain, with high success rates of surgical intervention. Because early weightbearing rehabilitation correlates with better surgical results, the integrity of anchors employed in these surgeries needs to be evaluated for proper fixation strength, leading to improved postoperative outcomes. The ultrasonically interdigitated anchor is a biodegradable suture anchor that is melted into bony trabeculae using ultrasound, leaving a small biological footprint and less interference on computed tomography and magnetic resonance imaging scans, without loss of fixation strength. We performed a review of 44 patients aged 26 to 84 years treated with either ultrasonically interdigitated anchors or fully threaded titanium anchors during Haglund's deformity excision. Overall, 7 of 14 patients who received an ultrasonically interdigitated anchor reported raw PROMIS (Patient-Reported Outcomes Measurement Information System) scores averaging 14.3, with an average return to ambulation time of 4.2 weeks. Fifteen of 30 patients receiving a fully threaded titanium anchor reported raw PROMIS scores averaging 9.7, with an average return to ambulation time of 3.5 weeks. We found little difference between the outcomes between the 2 anchors and no massive failures or infections in either group, implying that ultrasonically interdigitated anchors are a viable option for Achilles tendon reattachment during Haglund's deformity repair surgery.Levels of Evidence: Level III: Case control study.

Preliminary Evaluation of the Efficacy of Postoperative Early Weight-bearing Rehabilitation Protocol for Patients after Double-level Osteotomy.

ABSTRACTObjective:There are no reports describing in detail postoperative rehabilitation after double-level osteotomy (DLO). Consequently, the establishment of a safe and effective rehabilitation protocol is required.Methods:This retrospective study included 26 patients with varus knees who underwent DLO. No patient had obvious fracture around the femoral osteotomy sites, as evaluated using computed tomography (CT) 3 weeks postoperatively. From 3 days postoperatively, gait training with early weight bearing was performed using our parallel bar protocol. Range of motion exercises were permitted as tolerated. Radiological evaluation was performed to confirm the presence or absence of fracture around the femoral osteotomy sites using CT at 3 weeks and X-ray at 6 weeks postoperatively. X-ray imaging 6 months postoperatively indicated no femoral correction loss. Additionally, the time from initiation to completion of the protocol and the time from initiation to achievement of independent gait were recorded.Results:No fractures around the femoral osteotomy sites in any patient were found using CT 3 weeks postoperatively and X-rays 6 weeks postoperatively. There was no correction loss at the femoral osteotomy site according to X-ray findings 6 months postoperatively. The mean time until completion of the parallel bar protocol was 19.8 ± 6.2 (7–30) days, and that from the initiation of rehabilitation to the achievement of independent gait was 26.8 ± 7.1 (16–45) days.Conclusion:Patients without fracture around the femoral osteotomy site during the rehabilitation period could achieve independent gait within an average of <1 month using the parallel bar protocol. Early weight-bearing walking and independent walking could be achieved using this protocol.

Acute Achilles Tendon Ruptures: Efficacy of Conservative and Surgical (Percutaneous, Open) Treatment—A Randomized, Controlled, Clinical Trial

There is controversy regarding the best treatment for acute ruptures of the Achilles tendon. Multiple treatments present good results in the short and long term, none being superior to the other if a protocol of rehabilitation with full early weightbearing rehabilitation is followed. The objective of this study was to provide evidence on the efficacy and safety of conservative or surgical (percutaneous or open) treatment for acute Achilles tendon rupture. A randomized, controlled, parallel-groups, pilot clinical trial was performed in patients aged ≥18 years who arrived at the emergency room of our center experiencing acute Achilles tendon rupture. Patients were randomized via a computer-generated list to receive 1 of 3 treatments (conservative, percutaneous surgery, or open surgery). All patients followed the same protocol of rehabilitation with early weightbearing. A responder (i.e., successful treatment) was defined as capable of standing heelrise mono- and bipodally for 3 seconds, having a pain score ≤2 (verbal numerical rating scale) after walking, and having returned to active previous life (sport) at 1-year follow-up. From 2014 to 2017, 34 consecutive patients (median age, 41 years [range 18 to 59]; 32 male [94%]) were included: 11 conservative treatment, 11 percutaneous surgery, and 12 open surgery. At 1-year follow-up, the proportion of responders was 100% (11/11, 95% confidence interval [CI] 74% to 100%), 82% (9/11, 95% CI 52% to 95%), and 83% (10/12, 95% CI 55% to 95%), respectively. There was no case of total rerupture. Similar efficacy was found for conservative, percutaneous, and open surgery treatments for acute Achilles tendon rupture at 1-year follow-up with an early weightbearing rehabilitation program.

Current concepts in the rehabilitation of an acute rupture of the tendo Achillis

Rupture of the tendo Achillis is a common injury with a rising incidence. Traditionally the key question following this injury has been whether or not to operate. However a contemporary Cochrane review highlighted that the method of rehabilitation may also have an important contribution to the outcome. Since this review, various early weight-bearing rehabilitation protocols have been described. Currently evidence points to the use of early functional rehabilitation, regardless of operative or non-operative management. However, there is no consensus on which exact functional rehabilitation protocol should be used. Future research should be directed towards improving our understanding of how the different rehabilitative components interact in the tendo Achillis as it heals.

Prolonged progressive calcaneal bone loss despite early weightbearing rehabilitation in patients surgically treated for Achilles tendinosis.

We prospectively evaluated areal bone mineral density (BMD) of the calcaneus and calf-muscle strength (concentric and eccentric plantar flexion peak torque in Nm) in 10 recreational athletes (5 males and 5 females), mean age 40.9 years (range 26-55), who were selected to undergo surgical treatment for chronic Achilles tendinosis localized at the 2-6 cm level. Surgery was followed by immobilization in a plaster cast for 2 weeks, followed by flexibility training and slowly progressing strength training and weight-bearing activity. One patient was excluded after week 0 because of a new injury. Seven patients were back to their preinjury activity at the 26-week control, and eight patients at the 52-week control postoperatively. BMD in the calcaneus and calf-muscle strength on the injured and noninjured side was measured preoperatively (week 0) and postoperatively (weeks 2, 6, 16, 26, and 52). There were no significant differences in BMD between the injured and noninjured side at weeks 0, 2, and 6, but at weeks 16, 26, and 52, BMD was significantly (P < 0.05) lower (11.5%, 18.4%, and 16.4%, respectively) in the calcaneus of the injured side. Concentric and eccentric plantar flexion strength were significantly lower on the injured side preoperatively. Eccentric, but not concentric plantar flexion strength had recovered compared with the noninjured side 1 year postoperatively. Calf-muscle strength was not related to bone mass in the calcaneus. As a comparison, we used a group of 11 recreational athletes (10 males and 1 female), with a mean age of 46.1 years (range 28.9-58.5) who had been surgically treated for chronic Achilles tendinosis at the 2-6 cm level 39.5 +/- 11.8 months ago. In this group, there was no significant difference in BMD of the calcaneus between the injured and noninjured side. It seems that there was a delayed and prolonged calcaneal bone loss despite early weightbearing loading in patients surgically treated for chronic Achilles tendinosis at the 2-6 cm level. Around that time, when the Achilles tendon had healed (4-6 months) and the athletes returned to their sports, the calcaneal bone had a relatively low BMD and might possibly be vulnerable to heavy loadings. There were no signs of recovery 1 year postoperatively, but in a comparison group there were no significant side-to-side differences 39.5 months postoperatively.