Lower Leg Immobilization Research Articles

Outcomes comparison of elastic bandage versus lower-leg cast immobilization after anterior talofibular ligament repair

PurposeThe aim of this study was to compare the clinical outcomes between patients with chronic ankle instability (CAI) undergoing arthroscopic anterior talofibular ligament (ATFL) repair who received elastic bandage treatment and those who received lower-leg cast immobilization.MethodsCAI patients with isolated ATFL injury undergoing arthroscopic ATFL repair from January 2017 and August 2019 were included in the study. The visual analogue scale (VAS) at rest and during activities, American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (Karlsson score), and time of returning to walk, walk normally, work and sports were evaluated preoperatively, and at 6 months and 12 months follow-up.ResultsA total of 41 patients were included in this study. Among them, 24 patients accepted lower-leg cast fixation, and the other 17 patients were immobilized with elastic bandage. Compared to patients with lower-leg immobilization, patients with elastic bandage fixation had significantly lower VAS during activities (P = 0.021) and higher AOFAS score (P = 0.015) at 12 months follow-up. The Karlsson score at 6 months follow-up were significantly higher in elastic bandage group than those in lower-leg group (P = 0.011). However, no significant difference was observed in time of returning to walk, work and sports between the two groups.ConclusionElastic bandage treatment was better than lower-leg cast immobilization in terms of eliminating pain symptom at 12 months follow-up, and improving ankle functional outcome at 6 months follow-up. Moreover, the present study emphasized that lower-leg cast immobilization offered no advantages in arthroscopic ATFL repair postoperative immobilization.Study designCohort study; Level of evidence, 3.

Prevention of venous thromboembolic events in patients with lower leg immobilization after trauma: Systematic review and network meta-analysis with meta-epsidemiological approach.

BackgroundLower limb trauma requiring immobilization is a significant contributor to overall venous thromboembolism (VTE) burden. The clinical effectiveness of thromboprophylaxis for this indication and the optimal agent strategy are still a matter of debate. Our main objective was to assess the efficacy of pharmacological thromboprophylaxis to prevent VTE in patients with isolated temporary lower limb immobilization after trauma. We aimed to estimate and compare the clinical efficacy and the safety of the different thromboprophylactic treatments to determine the best strategy.Methods and findingsWe conducted a systematic review and a Bayesian network meta-analysis (NMA) including all available randomized trials comparing a pharmacological thromboprophylactic treatment to placebo or to no treatment in patients with leg immobilization after trauma. We searched Medline, Embase, and Web of Science until July 2021. Only RCT or observational studies with analysis of confounding factors including adult patients requiring temporary immobilization for an isolated lower limb injury treated conservatively or surgically and assessing pharmacological thromboprophylactic agents or placebo or no treatment were eligible for inclusion. The primary endpoint was the incidence of major VTE (proximal deep vein thrombosis, symptomatic VTE, and pulmonary embolism-related death). We extracted data according to Preferred Reporting Items for Systematic Reviews and Meta-analyses for NMA and appraised selected trials with the Cochrane review handbook. Fourteen studies were included (8,198 patients). Compared to the control group, rivaroxaban, fondaparinux, and low molecular weight heparins were associated with a significant risk reduction of major VTE with an odds ratio of 0.02 (95% credible interval (CrI) 0.00 to 0.19), 0.22 (95% CrI 0.06 to 0.65), and 0.32 (95% CrI 0.15 to 0.56), respectively. No increase of the major bleeding risk was observed with either treatment. Rivaroxaban has the highest likelihood of being ranked top in terms of efficacy and net clinical benefit. The main limitation is that the network had as many indirect comparisons as direct comparisons.ConclusionsThis NMA confirms the favorable benefit/risk ratio of thromboprophylaxis for patients with leg immobilization after trauma with the highest level of evidence for rivaroxaban.Trial registrationPROSPERO CRD42021257669.

Prevention of Venous Thromboembolic Events in Patients with Lower Leg Immobilization after Trauma: Systematic Review and Network Meta-Analysis with Meta-Epidemiological Approach

Prevention of Venous Thromboembolic Events in Patients with Lower Leg Immobilization after Trauma: Systematic Review and Network Meta-Analysis with Meta-Epidemiological Approach

Does deep venous thrombosis prophylaxis benefit patients with lower-leg immobilization?

Does deep venous thrombosis prophylaxis benefit patients with lower-leg immobilization?

Allopurinol partially prevents disuse muscle atrophy in mice and humans

Disuse muscle wasting will likely affect everyone in his or her lifetime in response to pathologies such as joint immobilization, inactivity or bed rest. There are no good therapies to treat it. We previously found that allopurinol, a drug widely used to treat gout, protects muscle damage after exhaustive exercise and results in functional gains in old individuals. Thus, we decided to test its effect in the prevention of soleus muscle atrophy after two weeks of hindlimb unloading in mice, and lower leg immobilization following ankle sprain in humans (EudraCT: 2011-003541-17). Our results show that allopurinol partially protects against muscle atrophy in both mice and humans. The protective effect of allopurinol is similar to that of resistance exercise which is the best-known way to prevent muscle mass loss in disuse human models. We report that allopurinol protects against the loss of muscle mass by inhibiting the expression of ubiquitin ligases. Our results suggest that the ubiquitin-proteasome pathway is an appropriate therapeutic target to inhibit muscle wasting and emphasizes the role of allopurinol as a non-hormonal intervention to treat disuse muscle atrophy.

OP-01 - Treatment of sarcopenia by targeting Akt and muscle specific ubiquitin ligases. Evidence from mice and from a clinical trial

Disuse muscle wasting may take place as a result of several such as joint immobilization, inactivity or bed rest. There are no good therapies to treat it. Allopurinol, a drug commonly used to treat hyperuricemia and gout, protects muscle damage, specially after exhaustive exercise and results in functional gains in old persons. Thus, we tested its effect in the prevention of atrophy of the soleus muscle after two weeks of hindlimb unloading in experimental animals (mice), and lower leg immobilization following ankle sprain in humans (Registration of the clinical Trial: EUDRACT2011-003541-17). We have found show that allopurinol protects against muscle atrophy in both mice and humans. The protective effect of allopurinol is similar, or even superior, to that of resistance exercise which is the best-known way to prevent muscle mass loss in disuse human models. We have also found that allopurinol protects against muscle mass loss by inhibiting the expression of ubiquitin ligases. Thus, the ubiquitin-proteasome pathway is an adequate therapeutic target to inhibit muscle wasting and underpins the role of allopurinol as a non-hormonal intervention to treat disuse muscle atrophy.

Deep Venous Thrombosis and Tendon Healing.

Tendon metabolism after acute Achilles tendon rupture (ATR) is associated with major complications related to immobilization, which results in reduced circulation, high risk of deep venous thrombosis (DVT), impaired healing and functional deficits.DVT has been demonstrated to occur in up to 50 % of the patients with ATR. Suffering from a DVT during tendon healing has been demonstrated as an independent predictive factor for impaired patient outcome at 1year after ATR, suggesting that specific interventions are warranted to prevent DVT. Since pharmacological DVT prophylaxis has low or no effect during lower leg immobilization it is speculated whether adjuvant treatment with intermittent pneumatic compression (IPC) applied during lower limb immobilization can reduce the incidence of DVT.IPC, which acts through mechanical, chemical and molecular mechanisms, has been demonstrated to enhance neuro-vascular ingrowth in a tendon repair model and stimulate collagen production leading to improved maximum force during healing.Recently, a prospective randomized trial compared adjuvant IPC applied under an orthosis versus plaster cast only in ATR patients. The study found at 2weeks post-operatively 21 % DVTs in the IPC-group compared to 37 % in the control group. Patients that received no IPC treatment exhibited an almost threefold increased odds for DVT, independently of age. Furthermore, using microdialysis technique, adjuvant IPC treatment was shown to increase the metabolic healing activity at 2weeks post-ATR.Tendon healing is impaired by reduced circulation and DVT. The demonstration that adjuvant IPC effectively reduced DVT incidence, and also is capable of enhancing the metabolic response suggests that IPC treatment may not only be a viable means of prophylaxis against DVT, but possibly also a method of promoting healing.

Low molecular weight heparin for prevention of venous thromboembolism in patients with lower-leg immobilization.

Immobilization of the lower leg is associated with venous thromboembolism (VTE). Low molecular weight heparin (LMWH) is an anticoagulant treatment which might be used in adult patients with lower-leg immobilization to prevent deep venous thrombosis (DVT) and its complications. This is an update of the review first published in 2008. To assess the effectiveness of low molecular weight heparin for the prevention of venous thromboembolism in patients with lower-leg immobilization in an ambulant setting. For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched June 2013) and CENTRAL (2013, Issue 5). Randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that described thromboprophylaxis by means of LMWH compared with no prophylaxis or placebo in adult patients with lower-leg immobilization. Immobilization was by means of a plaster cast or brace. Two authors independently assessed trial quality and extracted data. The review authors contacted the trial authors for additional information if required. Statistical analysis was carried out using Review Manager (RevMan 5). We included six RCTs fulfilling the above criteria with a total of 1490 patients. We found an incidence of VTE ranging from 4.3% to 40% in patients who had a leg injury that had been immobilized in a plaster cast or a brace for at least one week and who received no prophylaxis, or placebo. This number was significantly lower in patients who received daily subcutaneous injections of LMWH during immobilization (event rates ranging from 0% to 37%; odds ratio (OR) 0.49; fixed 95% confidence interval (CI) 0.34 to 0.72; with minimal evidence of heterogeneity with an I(2) of 20%, P = 0. 29). Comparable results were seen in the following subcategories: operated patients, conservatively treated patients, patients with fractures, patients with soft-tissue injuries, patients with proximal thrombosis, patients with distal thrombosis and patients with below-knee casts. Complications of major bleeding events were extremely rare (0.3%) and there were no reports of heparin-induced thrombocytopenia. Use of LMWH in outpatients significantly reduces VTE when immobilization of the lower leg is required.

A longitudinal MRI study of muscle atrophy during lower leg immobilization following ankle fracture

To investigate MRI biomarkers of muscle atrophy during cast immobilization of the lower leg. Eighteen patients (8 male, 10 female), who had one lower leg immobilized in a cast, underwent 3.0 Tesla (T) MR imaging 5, 8, 15, 29, and 43 days after casting. Measurements were made on both lower legs of total muscle volume. Cross-sectional area (CSA), fractional water content, and T(2) were measured in tibialis anterior (TA), gastrocnemius medialis (GM) and lateralis (GL) and soleus (SOL). Fiber pennation angle was measured in GM. Total muscle volume decreased by 17% (P < 0.001) over the 6 weeks of immobilization. The greatest loss in CSA (mean[SD]) was seen in GM (-23.3(8.7)%), followed by SOL (-19.0(9.8)%), GL (-17.1(6.5)%), and TA (-10.7(5.9)%). Significant reductions of CSA were also detectable in the contra-lateral leg. T(2) increased in all muscles: TA 27.0(2.5) ms to 29.6(2.8) ms (P < 0.001), GM 34.6(2.9) ms to 39.8(5.4) ms (P < 0.001) and SOL 34.4 (2.9) ms to 44.9(5.9) ms (P < 0.001). Small reductions were found in fractional water content. Pennation angle decreased in the cast leg (P < 0.001). Quantitative MR imaging can detect and monitor progressive biochemical and biophysical changes in muscle during immobilization.

Insufficient Evidence for Routine Use of Thromboprophylaxis in Ambulatory Patients with an Isolated Lower Leg Injury Requiring Immobilization: Results of a Meta-Analysis.

There are no generally accepted guidelines for the prevention of venous thromboembolism (VTE) in ambulatory patients requiring immobilization after an isolated lower leg injury. Our objective was to evaluate the effectiveness and safety of pharmacological interventions for preventing VTE in these patients. Meta-analysis of randomized controlled trials. We searched PubMed/Medline, EMBASE and the Cochrane Central Register of Controlled Trials for trials with random allocation of thromboprophylaxis, notably low molecular weight heparin (LMWH) versus no prophylaxis or placebo, in ambulatory patients with below-knee or lower leg (including the knee joint) immobilization. Outcome was analyzed using MIX to calculate the pooled risk ratio/relative risk (RR) for each outcome, along with its 95% confidence interval (CI). The RR of asymptomatic deep vein thrombosis (DVT) was 0.66 (95% CI 0.44; 1.02) for below-knee immobilization and 0.51 (95% CI 0.37; 0.70) for lower leg immobilization. Low molecular weight heparin versus no prophylaxis or placebo was evaluated. The incidence of symptomatic DVT and PE was too low to show any statistically significant difference between thromboprophylaxis and controls in both groups. Although only one adverse bleeding event was considered to bemajor, the RR for any adverse bleeding event was 1.94 (95% CI 1.03; 3.67). There is insufficient evidence to warrant routine use of thromboprophylaxis in ambulatory patients with below-knee or lower leg immobilization after an isolated lower leg injury. The incidence of symptomatic VTE is too low to show a relevant clinical benefit from thromboprophylaxis.

Prevention of venous thromboembolism in patients with immobilization of the lower extremities: a meta-analysis of randomized controlled trials.

It is controversial whether the prevention of venous thromboembolism (VTE) in patients with lower-leg immobilization is necessary. To assess the benefits and complications of pharmacological thromboprophylaxis, we performed a meta-analysis of all available randomized controlled trials on this subject. We searched the MEDLINE and EMBASE electronic databases. We included English- and non-English language studies, we hand-searched journals, and we contacted manufacturers. We analyzed data from six randomized trials that investigated pharmacological prophylaxis for the prevention of VTE in 1456 patients with lower-leg immobilization in plaster cast or orthosis. Two reviewers independently assessed the trials for inclusion, extracted data, and assessed trial quality. Differences were resolved by consensus or arbitrage. The pooled estimate from all trials revealed a highly significant and clinically relevant reduction in asymptomatic events with low-molecular-weight heparin (LMWH) prophylaxis, compared to placebo or untreated control [risk ratio (RR) 0.58; 95% confidence interval (CI) 0.39-0.86; P = 0.006). The mean rate of VTE decreased from 17.1% to 9.6% with the use of LMWH. Subgroup analysis of methodologically superior trials (RR 0.68; CI 0.50-0.92; P = 0.01), proximal deep vein thrombosis (RR 0.28; CI 0.11-0.72; P = 0.008), tendon ruptures (RR 0.60; CI 0.38-0.97; P = 0.04), and fractures (RR 0.62; CI 0.45-0.86; P = 0.004) confirmed the robustness of the overall result. Frequency of bleeding did not differ between LMWH prophylaxis and control groups (RR 1.22; CI 0.61-2.46; P = 0.57). Our findings indicate that thromboprophylaxis with LMWH for immobilization of the lower extremities reduces the risk of VTE. This benefit is achieved with no excess bleeding.

A water‐pad placed under the plaster may prevent deep venous thrombosis by counteracting venous stasis during periods of lower leg immobilization

A water‐pad placed under the plaster may prevent deep venous thrombosis by counteracting venous stasis during periods of lower leg immobilization

Counteracting venous stasis during acute lower leg immobilization

During lower limb immobilization, patients are at risk to develop deep venous thrombosis. Recently, a water-pad was developed that should counteract venous stasis. The water-pad, located under the plaster, mobilizes water from the foot to the calf during weight bearing and, thereby, imitates muscle pump function. The purpose of this study was to assess the effect of the water-pad on venous pump function in healthy individuals. In 21 healthy subjects (10 men and 11 women) both legs were plastered. Venous pump function was assessed by plethysmography measuring lower leg venous ejection fraction and volume. Subjects were tilted from the supine position to upright standing to determine total venous volume. Hereafter, stepping was performed to measure venous ejection fraction and volume under different filling conditions of the water-pad (0, 50, 100, 150, 200, 250 and 300 mL). Different sizes of water-pads (small, medium and large) were applied to each plastered leg in order to test the effectiveness and to relate optimum size to anthropometrical data. The venous ejection fraction increased significantly from 30 +/- 17% to a maximum of 42 +/- 19% during stepping with increasing filling condition (RM anova; P = 0.009). Ejection volume also enhanced significantly during stepping with increasing filling condition from 1.3 +/- 0.7 to 1.9 +/- 0.9 mL (100 mL)(-1) (RM ANOVA; P = 0.006). The optimal filling condition of the water-pad depended on the water-pad size, while body height was the best predictive value for the water-pad size (Pearson's R = 0.72, P < 0.001). The filled water-pad markedly increased the venous ejection fraction and volume of the lower leg during stepping, hereby counteracting stasis of venous blood in the immobilized lower leg. Therefore, the water-pad seems to be a promising tool to prevent deep venous thrombosis during periods of lower leg immobilization.

Longitudinal study of skeletal muscle adaptations during immobilization and rehabilitation

This study describes the metabolic, morphologic, neurologic, and functional adaptations observed in the plantar flexors during 8 weeks of lower leg immobilization and 10 weeks of physical therapy following ankle surgery. A combination of magnetic resonance imaging and spectroscopy, isokinetic and isometric muscle testing, and simple functional tests revealed many adaptive changes due to immobilization, including atrophy, loss of muscle strength, reduced central activation, increase in fatigue resistance, and an increase in inorganic phosphate content. After 10 weeks of physical therapy all alterations were reversed, with the exception of a remaining 5.5% deficit in total muscle cross-sectional area.