Nonweightbearing Cast Immobilization Research Articles

IMMEDIATE WEIGHT BEARING FOLLOWING ANKLE FRACTURE FIXATION IS LESS COSTLY AND MORE EFFECTIVE THAN NON-WEIGHT BEARING: INWN TRIAL RESULT

Is Non-Weight-Bearing Necessary? (INWN) is a pragmatic multicentre randomised controlled trial comparing immediate protected weight-bearing (IWB) with non-weight-bearing cast immobilisation (NWB) following ankle fracture fixation (ORIF). This trial compares; functional outcomes, complication rates and performs an economic analysis to estimate cost-utility.IWB within 24hrs was compared to NWB, following ORIF of all types of unstable ankle fractures. Skeletally immature patients and tibial plafond fractures were excluded. Functional outcomes were assessed by the Olerud-Molander Ankle Score (OMAS) and RAND-36 Item Short Form Survey (SF-36) taken at regular follow-up intervals up to one year. A cost-utility analysis via decision tree modelling was performed to derive an incremental cost effectiveness ratio (ICER). A standard gamble health state valuation model utilising SF-36 scores was used to calculate Quality Adjusted Life Years (QALYs) for each arm.We recruited 160 patients (80 per arm), aged 15 to 94 years (M = 45.5), 54% female. Complication rates were similar in both groups. IWB demonstrated a consistently higher OMAS score, with significant values at 6 weeks (MD=10.4, p=0.005) and 3 months (MD 12.0, p=0.003). Standard gamble utility values demonstrated consistently higher values (a score of 1 equals perfect health) with IWB, significant at 3 months (Ẋ = 0.75 [IWB] / 0.69 [NWB], p=0.018). Cost-utility analysis demonstrated NWB is €798.02 more expensive and results in 0.04 fewer QALYs over 1 year. This results in an ICER of −€21,682.42/QALY. This negative ICER indicates cost savings of €21,682.42 for every QALY (25 patients = 1 QALY gain) gained implementing an IWB regime.IWB demonstrates a superior functional outcome, greater cost savings and similar complication rates, compared to NWB following ankle fracture fixation.

Weight-bearing Allowed Following Internal Fixation of Ankle Fractures, a Systematic Literature Review and Meta-Analysis.

Postoperative management regimes vary following open reduction and internal fixation of unstable ankle fractures. Traditional postoperative nonweightbearing cast immobilization may prevent loss of fixation and protect the soft tissue envelope but may also be associated with poorer functional outcomes. This systematic review and meta-analysis aimed to compare the complication rate and functional outcomes of early weightbearing (EWB) vs late weightbearing (LWB) following open reduction and internal fixation of ankle fractures. We performed a systematic review with a meta-analysis of controlled trials and comparative cohort studies using 3 databases. We included all studies that investigated the effect of weightbearing following internal fixation of ankle fractures in adult patients by any means. Studies that investigated mobilization but not weightbearing, non-English-language publications, and tibial Plafond fractures were excluded from this systematic review. We assessed the risk of bias using ROB 2 tools for randomized controlled trials and ROBINS-1 for cohort studies. Data extraction was performed using Covidence online software and meta-analysis by using RevMan 5.3. This systematic review included 10 randomized controlled trials and 4 comparative cohort studies. Most of the included studies were rated as having some concern with regard to the risk of bias. There was no significant difference in the complication rate between the protected EWB and LWB groups (the risk ratio [RR] for infection was 1.30, 95% CI 0.74, 2.30; I² = 0%; P = .36), but better functional outcome scores were detected in the EWB group only at 6 weeks postoperatively (MD =10.08, 95% CI 5.13, 15.02; I² = 0%; P ≤ .0001), with no significant difference seen at 6 or 12 months postoperatively. Based on the studies reviewed, it appears that early protected weightbearing following open reduction and internal fixation of ankle fractures does not affect surgical incision or fracture healing and is associated with better early functional outcomes at 6 weeks, but not 6 or 12 months, postoperatively.

Transcuneiform Crush Injury: A Case Report

Introduction: Transcuneiform fracture patterns without dislocations are uncommon. In a review of the literature, numerous case reports describe cuneiform fracture-dislocations involving either the transmetatarsal or midtarsal joint complexes due to direct trauma; however, an isolated transcuneiform fracture pattern without dislocation has not been reported. Methods: We present a rare injury of the foot: an isolated transcuneiform fracture without associated dislocation of the tarsometatarsal joint or midtarsal joint complex. Case: A 29 year old active duty Army male sustained direct blunt trauma to his foot when a 20 ton trailer fell onto it. His initial presentation prompted protected weight bearing after a clinical exam revealed soft tissue injury and tenderness to palpation about the dorsum of his midfoot. Due to persistent symptoms, he was referred to a musculoskeletal specialist. Radiographs and computed tomography (CT) images demonstrated a minimally displaced comminuted transcuneiform fracture involving the medial and intermediate cuneiforms without evidence of dislocation or subluxation. Treatment consisted of non-weight bearing cast immobilization with crutches for ten weeks before being transitioned into a weight bearing control ankle motion (CAM) boot. Radiographic evidence of healing was documented at 4 weeks by callus formation at the first metatarsal and medial cuneiform. The patient returned to low impact activity by 10 month follow-up without surgical intervention. Discussion and Conclusions: Blunt trauma to the midfoot can result in isolated or complex fracture patterns without the typical fracture-dislocation following high mechanism trauma. Appropriate clinical suspicion and careful physical examination can facilitate timely diagnosis and treatment. Minimally displaced transcuneifom fracture patterns without associated midfoot dislocation injuries can be treated nonoperatively with protected weight bearing, close radiographic and clinical follow up, and gradual advancement to activity with acceptable clinical outcomes.

A Posterior 3-Portal Arthroscopic Approach for Isolated Subtalar Arthrodesis

Arthroscopic subtalar arthrodesis was developed to improve on open methods of fusion. A posterior 3-portal arthroscopic approach with the patient in the prone position provides a new and optimal method for isolated subtalar arthrodesis. It facilitates safe access to the posterior talocalcaneal facet. The posterolateral portal was established using blunt dissection. The 3-mm, 30° arthroscope was inserted, the posterolateral portal was made, and synovectomy carried out. A large 4-mm arthroscope was used to improve fluid flow. The third portal was then established approximately 1 cm proximal and 1 cm posterior to the tip of the lateral malleolus. This portal was used for distraction by inserting a large blunt trocar into the joint. Most of the procedure was performed with the arthroscope in the posterolateral portal and the instruments posteromedial. Allograft was inserted through the posterolateral portal. Fixation was achieved using 2 cannulated 6.5- or 7.3-mm cancellous screws, inserted under fluoroscopic control. Postoperatively, patients were assigned to non-weight bearing cast immobilization with crutch ambulation for 6 weeks, followed by gradual weight bearing until radiographs showed union. Preliminary results have shown high patient satisfaction, an excellent fusion rate, and less postoperative morbidity than with open subtalar arthrodesis.

Stress Fractures of the Medial Malleolus

Medial malleolar stress fractures account for only 10% of all stress fractures of the foot and ankle, but they can cause significant disability and loss of participation time, particularly in high-level athletes. They are most common in patients between the ages of 20 and 40 years and occur almost exclusively in athletes involved in sports that involve running and jumping. Medial malleolar stress fractures are considered at high risk for progression to complete fracture, delayed union, or nonunion and often are treated as acute fractures. An aggressive nonoperative protocol of nonweight-bearing cast immobilization (usually for 6 weeks) may be successful if the stress fracture is diagnosed soon after symptoms appear, but time to complete healing and safe return to activity may be as long as 6 to 8 months, an unacceptable solution for most elite athletes. Open reduction and internal fixation with 2 or 3 fully threaded cortical screws generally allow faster healing and return to activity when compared with nonoperative treatment.

Navicular stress fractures: outcomes of surgical and conservative management

Objective: To compare the long term outcomes of the two treatment options for navicular stress fractures: non-weightbearing cast immobilisation and surgical fixation. Design: Retrospective case study. Participants: Subjects aged 18...

Tarsal Navicular Stress Injury

Background Tarsal navicular stress fracture is a condition that has curtailed many athletic careers. Management protocols remain varied and somewhat controversial. Hypotheses (1) Clinical practice does not mirror the recommendations reported from previous case series. (2) Clinical outcome is poor when navicular stress fracture is managed in a variety of ways. (3) Imaging does not correlate strongly with clinical status at long-term follow-up after navicular stress fracture. Study Design Case series (prognosis); Level of evidence, 4. Methods From a computer registry, we identified patients who had attended a university sports medicine center between 1996 and 2002 and whose final diagnosis was navicular stress fracture (n = 11) or navicular stress reaction (n = 9). All patients had provided demographic and clinical data at their original evaluation, and all had undergone bone scans and computed tomographic imaging. These data were extracted by chart review. Follow-up clinical and imaging assessments took place a median of 3.7 years later (range, 1-15.7 years). At these assessments, we administered a questionnaire, performed a structured physician examination (blinded to other data), scanned both feet with computed tomography, and obtained magnetic resonance images of the affected foot. Results Only 2 of 11 patients (18%) with navicular stress fractures received the literature-recommended treatment of at least 6 weeks’ nonweightbearing cast immobilization. Of these 11 patients, only 6 (55%) returned to sports at their previous level. Only 3 patients with navicular stress fractures regained normal imaging appearance at follow-up. Pain score, stiffness, sporting success, current sporting involvement, and recurrence/time to recurrence were not statistically associated with computed tomographic or magnetic resonance imaging parameters. Of 9 patients with navicular stress reactions, 7 developed clinical and radiological features of navicular stress fracture, but 6 of 9 patients (67%) returned successfully to sports. Conclusions Contemporary management of navicular stress fracture differs from that recommended in the literature. This stress fracture prevented almost half of the participants in this study from returning to sports at their previous level. Imaging parameters do not correlate with the clinical assessment of a patient at long-term follow-up of navicular stress fracture.

Navicular Stress Fractures

Navicular stress fractures are a common and debilitating condition in running athletes, hence the need for early accurate treatment strategies. The two predominant treatment modalities are nonweight bearing cast immobilization (NWBCI), and surgical fixation. While both effective over the shorter term, there is controversy as to the superior treatment over the longer term. AIMS To investigate long-term treatment outcomes of navicular stress fractures. METHODS A cross-sectional research design was used. Subjects had been treated for a navicular stress fracture and had returned to full competition after the injury more than 2 years previously. They completed a questionnaire then underwent a physical examination and CT scan. RESULTS Thirty two stress fractures in 26 subjects were investigated by questionnaire. Of these, 29 fractures in 23 subjects were examined clinically and by CT scan. No statistically significant difference was found between surgical and conservative management for any of Current Pain (p = 0.984), Current Function, (p = 0.170) or Abnormality on CT (p = 0.173). However surgically treated patients more often remained tender over the 'N spot' (p = 0.005) even after >2 years return to competition. A difference was found between injured and noninjured foot for Current Pain (p <0.001) and Current Function (p = 0.019). CONCLUSION The evidence from this study suggests that surgical fixation of navicular stress fractures is an equally effective treatment, compared to conservative management, over the longer term. However there remains a small, though measurable degree of pain and loss of function for patients over this period.

59 Mavicular stress fractures: outcomes of conservative and surgical management

Navicular stress fractures are a common and debilitating condition in running athletes, hence the need for early accurate treatment strategies. The two predominant treatment modalities are nonweightbearing cast immobilization (NWBCI), and surgical fixation. While both effective over the shorter term, there is controversy as to the superior treatment over the longer term. AIMS: To investigate long-term treatment outcomes of navicular stress fractures. METHODS: A cross-sectional research design was used. Subjects had been treated for a navicular stress fracture and had returned to full competition after the injury more than 2 years previously. They completed a questionnaire then underwent a physical examination and CT scan. RESULTS: Thirty two stress fractures in 26 subjects were investigated by questionnaire. Of these, 29 fractures in 23 subjects were examined clinically and by CT scan. No statistically significant difference was found between surgical and conservative management for any of Current Pain (p = 0.984), CurrentFunction, (p = 0.170) or Abnormality on CT (p = 0.173). However surgically treated patients more often remained tender over the 'N spot' (p = 0.005) even after >2 years return to competition. A difference was found between injured and noninjured foot for Current Pain (p < 0.001) and Current Function (p = 0.019).CONCLUSION:The evidence from this study suggests that surgical fixation of navicular stress fractures is an equally effective treatment, compared to conservative management, over the longer term. However there remains a small, though measurable degree of pain and loss of function for patients over this period.

Stress fractures in runners

Stress fractures, were first described in military recruits but in recent years have increasingly been described in runners. In most surveys they comprise between 10 and 20% of all running injuries. The tibia is the most common site of all stress fractures although recent studies involving track and field athletes show an increased incidence of navicular stress fractures. The diagnosis is based on the clinical findings of a history of exercise-related bone pain with local bony tenderness on examination. The diagnosis is often confirmed by a typical appearance on an isotope bone scan or plain radiograph. In general, treatment consists of relative rest from the aggravating activity until symptom-free and then graduated resumption of activity. Attention also needs to be paid to correction of possible causative factors. These include excessive training, low bone density, low calcium intake, menstrual abnormalities in females and biomechanical features such as excessive sub-talar pronation. Certain stress fractures, such as those in the navicular, require specific management, e.g. six weeks non-weight bearing cast immobilization.

Tarsal navicular stress fracture in athletes.

Stress fracture of the tarsal navicular bone is now frequently recognised. The majority of navicular stress fractures are partial fractures in the sagittal plane. They occur mainly in track and field athletes. A number of theories regarding the aetiology of this fracture have been proposed. Athletes with a history of vague, activity-related midfoot pain, with associated tenderness over the dorsal proximal navicular ('N' spot) should be suspected of having a navicular stress fracture. Plain radiography frequently fails to demonstrate the fracture, thus radionuclide scanning is the investigation of choice to detect navicular stress injury. A computed tomography (CT) scan should be performed to confirm the presence of the fracture. Various methods of treatment have been employed. A minimum of 6 weeks of strict non-weightbearing cast immobilisation is the treatment of choice. After removal of the cast, a further 6 week programme of rehabilitation with a graduated return to activity, joint mobilisation and soft tissue massage is required. Surgery for nonunion or delayed union is rarely required if initial treatment is appropriate.

A Treatment Algorithm for Neuropathic (Charcot) Midfoot Deformity

Forty-nine feet in 47 patients with midfoot neuropathic foot deformity were referred for care to a comprehensive foot salvage clinic and followed for an average of 3.6 years. Twenty-three initially presented without open ulcers. Two underwent elective Syme's ankle disarticulation amputation, and the others were kept ambulatory with a combination of periods of nonweightbearing cast immobilization, accommodative extra-depth shoes with custom orthotics, and ankle-foot orthoses. Twenty-six of the feet initially presented for care with open ulcers and/or chronic osteomyelitis. Twenty-two of these patients underwent 32 surgical procedures. Sixteen underwent debridement of the infected bone and surrounding soft tissues. Excision of large, nonaccommodative boney prominence, termed exostectomy, was performed in eight. Partial excision of the deformed midfoot combined with boney stabilization and attempted arthrodesis, termed partial tarsectomy, were performed in seven. All surgical patients were managed postoperatively with long-term custom accommodative bracing. Follow-up at an average of 3.6 years revealed that all but one of the patients remained ambulatory. Six walk with accommodative shoe gear and persistent stable chronic open ulcers. None required below-knee amputation. Five amputations were performed, three at the Syme's ankle disarticulation level, one at the Chopart's hind-foot level, and one at the mid-foot level.(ABSTRACT TRUNCATED AT 250 WORDS)

Outcome of conservative and surgical management of navicular stress fracture in athletes. Eighty-six cases proven with computerized tomography.

Eighty-two athletes with 86 clinical navicular stress fractures, all imaged with computerized tomography, were followed for an average of 33 months (range, 6 to 108) after diagnosis. Initial treatment consisted of at least 6 weeks of nonweightbearing cast immobilization for 22 fractures, at least 6 weeks of limitation of activity with continued weightbearing for 34 fractures, and a period of less than 6 weeks of conservative treatment for another 19 fractures. Five patients attempted to continue playing sports. Six patients had immediate surgery. Nineteen of 22 patients (86%) who had initial non-weightbearing cast immobilization treatment returned to sports, compared with only 9 of 34 patients (26%) who initially continued weightbearing with limited activity (P < 0.001). After failure of the latter treatment, successful outcomes were seen for 6 of 7 patients (86%) treated with nonweightbearing cast immobilization, while 11 of 15 patients (73%) who had one surgical procedure were able to return to sports. These results indicate that nonweightbearing cast immobilization is the treatment of choice for navicular stress fractures. Also, this treatment compares favorably with surgical treatment for patients who present after failed weightbearing treatments. Computerized tomographic appearances of healing fractures do not necessarily mirror clinical union, and postimmobilization management should be monitored clinically.