Removable Cast Research Articles

Effectiveness of Removable Walker Cast Versus Nonremovable Fiberglass Off-Bearing Cast in the Healing of Diabetic Plantar Foot Ulcer

OBJECTIVETo evaluate the efficacy of a removable cast walker compared with that of a nonremovable fiberglass off-bearing cast in the treatment of diabetic plantar foot ulcer.RESEARCH DESIGN AND METHODSForty-five adult diabetic patients with nonischemic, noninfected neuropathic plantar ulcer were randomly assigned for treatment with a nonremovable fiberglass off-bearing cast (total contact cast [TCC] group) or walker cast (Stabil-D group). Treatment duration was 90 days. Percent reduction in ulcer surface area and total healing rates were evaluated after treatment.RESULTSA total of 48 patients were screened; however, 2 patients in the TCC group and 1 patient in the Stabil-D group did not complete the study and were considered dropouts. There were no significant differences in demographic and clinic characteristics of the 45 patients completing the study. Ulcer surface decreased from 1.41 to 0.21 cm2 (P < 0.001) in the TCC group and from 2.18 to 0.45 cm2 (P < 0.001) in the Stabil-D group, with no significant differences between groups (P = 0.722). Seventeen patients (73.9%) in the TCC group and 16 patients (72.7%) in the Stabil-D group achieved healing (P = 0.794). Average healing time was 35.3 ± 3.1 and 39.7 ± 4.2 days in the TCC and Stabil-D group, respectively (P = 0.708).CONCLUSIONSThe Stabil-D cast walker, although removable, was equivalent in efficacy to the TCC in terms of ulcer size reduction and total healing rate. The easier use of Stabil-D may help increase the use of off-loading devices in the management of plantar neuropathic diabetic foot ulcers.

Technical Notes and Tips: An Alternative Crossbar for Controlling Post-Operative Hip Rotation

A modified cast boot with a rotation bar can be used to control postoperative hip rotation, thereby reducing the incidence of further dislocation.1 A broom handle or other piece of dowel has traditionally been utilised as the rigid template for the cross-bar. Broom handles or pieces of doweling are not generally freely available in theatre. Fibreglass casting tape can be twisted around itself to form a solid bar. The fibreglass bar can be attached to a removable cast boot and control rotation of the hip joint in a simple and cost-effective manner (Fig. 1). Figure 1 Modified cast boot with cross-bar.

Effectiveness of Constraint-Induced Movement Therapy (CIMT) as Home-Based Therapy on Barthel Index in Patients with Chronic Stroke

Objective: The goal of this study is to investigate the effectiveness of constraint-induced movement therapy (CIMT) on the Barthel Index (BI) scores in persons with stroke to assess dependency in survivers of stroke and to investigate the long-term effects of CIMT on dependency needs as measured by the BI, based on the hypothesis that CIMT as home-based therapy would be of significant benefit in stroke rehabilitation. Methods: Twenty-seven participants, 16 men with a mean age of 58 (± 10.8) and 4 women with a mean age of 60 (± 6.3), participated in the study as an experimental group, and 17 participants, 12 men with a mean age of 58 (± 9.7) and 5 women with a mean age of 55 (±11.8), participated as a control group. The experimental/treatment group received traditional therapy with the CIMT where the intact contralateral upper limb was placed in a removable cast for 6 hours a day during waking hours for 4 weeks. The control group received traditional therapy only. Both groups were assessed using the BI on admission and on discharge from rehabilitation. In addition, 18 participants (14 male and 4 female), 64% of the experimental group, were reevaluated using the BI for the long-term benefits of CIMT on dependency. Results: Using unpaired t test (SPSS version 15), statistically significant improvement was noted in the BI for the experimental group compared to the control group. After 6 months follow-up, BI was 96.3 ± 2.7, indicating that the obtained gains were maintained at 6 months post discharge, compared to their BI score at 4 weeks (68.2 ± 3.8) post CIMT (p value < .005). Conclusion: Following stroke, patients who received CIMT every day for 4 weeks in conjunction with traditional rehabilitation therapy showed significant changes in the BI upon discharge and this positive outcome was preserved after 6 months follow-up. This improvement indicates an overall significant improvement in ADL status for patients who received CIMT and has implications for future use in stroke rehabilitation as home-based therapy for stroke rehabilitation.

Vacuum cushioned removable cast walkers reduce foot loading in patients with diabetes mellitus

BackgroundDiabetes mellitus is one of the most common diseases worldwide and the number of patients is expected to increase dramatically in future. Plantar ulceration is partly caused by high plantar pressures and a major complication in diabetic patients. PurposeThe aim of this study was to investigate the pressure-relieving effects of two vacuum orthoses in patients with diabetes mellitus. MethodsTwenty patients with diabetes mellitus were included. They presented with plantar callosities but no ulceration. Exclusion criteria included the use of walking aids and other systemic diseases. Plantar pressure distribution was measured with sensor insoles (Pedar-X, Novel GmbH) during walking in two vacuum orthoses, a post-operative shoe and an off-the-shelf shoe as reference condition. Statistical analysis was conducted using Friedman and Wilcoxon signed-rank tests. ResultsSignificant differences in plantar pressure distribution were found between the four walking conditions. The contact area increased in the midfoot with the vacuum orthoses. Maximum force and peak pressures showed a significant decrease under the rearfoot and forefoot and increased in the midfoot area during walking with both vacuum orthoses. The high-cut vacuum orthosis revealed equal pressure relief under the forefoot and significantly lower rearfoot pressures compared to the post-operative shoe. ConclusionsThe vacuum orthoses demonstrated a comparable pressure-relieving efficacy under the forefoot to post-operative shoes. Using vacuum orthosis significantly benefited re-distribution of plantar pressure and the roll-over process. Clinical significance of the pressure-relieving efficacy could not be confirmed in this investigation and has to be addressed in further studies.

The efficacy of a removable vacuum-cushioned cast replacement system in reducing plantar forefoot pressures in diabetic patients

Background The purpose of this study was to determine the plantar forefoot offloading efficacy of a new prefabricated vacuum-cushioned cast replacement system designed for foot ulcer treatment in neuropathic diabetic patients. Methods Fifteen diabetic subjects with peripheral neuropathy underwent in-shoe plantar pressure assessment while walking in five different footwear types: a standard vacuum-cushioned system with instantly moldable vacuum cushion and roller outsole, two modified vacuum-cushioned systems, one with flat surface vacuum cushion and one with flat outsole, a forefoot offloading shoe, and a control shoe. Regional peak pressures, pressure–time integrals, and inter-regional load transfers were calculated to determine the mechanical action of the footwear. Perceived walking comfort was tested using a 10-point visual analogue scale. Findings Forefoot peak pressures and pressure–time integrals were significantly lower (by 41–56%) in the vacuum-cushioned system compared to control. Compared to the forefoot offloading shoe, the vacuum-cushioned system showed significantly higher metatarsal head peak pressures, similar metatarsal head pressure–time integrals, and significantly lower hallux peak pressures and pressure–time integrals. A major transfer of forefoot load to the midfoot explained the offloading efficacy of the vacuum-cushioned system. Few significant differences were present between the modified and standard vacuum-cushioned systems. Perceived walking comfort was significantly higher in the vacuum-cushioned system (score 6.6) than in the forefoot offloading shoe (score 3.4). Interpretation The results showed that the vacuum-cushioned cast replacement system was effective in offloading the plantar forefoot of diabetic patients at risk for ulceration, although the contribution of the instantly moldable vacuum cushion and roller outsole were relatively small. The combined peak pressure, pressure–time integral and walking comfort results indicate that the vacuum-cushioned system may be a useful alternative for the forefoot offloading shoe in offloading the plantar diabetic forefoot.

Realignment Surgery for Valgus Ankle Osteoarthritis

Improvement of joint congruence, reduction of pain, slowdown of osteoarthritis progression, and prevention or delay of total ankle arthroplasty or ankle fusion. Active patients with lateral valgus ankle joint degeneration. Patients in poor general condition. Inability to adhere to postoperative non-weight-bearing rehabilitation. Distinct cartilage degeneration of more than half of tibiotalar joint surface. Systemic joint disease. Insufficiency of the deltoid ligament with tibiotalar subluxation malalignment. Depending on stage of deformity: Stage I--collapse of the lateral tibia plafond and/or lateral malleolar gutter with subsequent valgus ankle arthritis: medial closing-wedge osteotomy of the distal tibia. Derotation- lengthening osteotomy in case of fibula malunion. Stage II--excessive calcaneus valgus: add medial sliding calcaneus osteotomy. Stage III--forefoot-induced hindfoot valgus (flatfoot deformity with forefoot abduction): add repair/augmentation of the posterior tibial tendon, superficial delta and spring ligaments; gastrocnemius/triceps release; flexion osteotomy of the first cuneiform or metatarsal bone or fusion of the first tarsometatarsal joint. Continuous active and passive range of motion starting at the 2nd postoperative day. Removable short leg cast during nights. Partial weight bearing for 6-8 weeks until osseous healing has occurred, followed by gradual return to full weight bearing and activity. 14 patients with stage I, three with stage II, and five with stage III valgus ankle osteoarthritis were treated. In two cases realignment surgery failed and progressive painful arthritis was treated by arthroplasty. The other 20 patients improved at an average follow-up of 4.5 years (range 3-6.5 years). Eight patients (41%) were free of pain. Tibiotalar arthritis and alignment (Takakura Score) improved significantly and correlated with significant improvement of pain (visual analog scale) and function (American Orthopaedic Foot and Ankle Society Score).

A Method for Assessing Off-loading Compliance

Off-loading excessive pressure is essential to healing diabetic foot ulcers. However, many patients are not compliant in using prescribed footwear or off-loading devices. We sought to validate a method of objectively measuring off-loading compliance via activity monitors. For 4 days, a single subject maintained a written compliance diary concerning use of a removable cast walker. He also wore a hip-mounted activity monitor during all waking hours. An additional activity monitor remained mounted on the cast walker at all times. At the conclusion of the 4 days, the time-stamped hip activity data were independently coded for walker compliance by the compliance diary and by using the time-stamped walker activity data. An intraclass reliability of 0.93 was found between diary-coded and walker monitor-coded activity. These results support the use of this dual activity monitor approach for assessing off-loading compliance. An advantage of this approach versus a patient-maintained diary is that the monitors are not susceptible to incorrect patient recall or a patient's desire to please a caregiver by reporting inflated compliance. Furthermore, these results seem to lend support to existing reports in the literature using similar methods.

The advantages gained by the use of modern materials in the post operative casting procedure for foot and ankle surgery

In June 2006, the post operative plaster immobilisation protocol for patients undergoing hindfoot and ankle surgery, at our institution, changed from multiple plaster changes to the immediate application of a definitive removable and reusable split synthetic cast. This study aims to assess the savings to the hospital and patient, following this change in practice. A retrospective analysis of plaster room records from June 2005 to June 2007 was performed. The difference in cost to the hospital of the two different post operative journeys was then calculated. Two-hundred and twenty-two patients from 2005 to 2006 were managed at a total cost of 97,125 euro. From 2006 to 2007, 203 patients were managed with the new technique at a total cost of 37,860 euro. The net saving to the hospital of this change in practice was 251 euro per patient and 50,953 euro in total, while 203 patient visits and costs associated therewith were also saved. This study demonstrates how small changes in local practice can result in significant financial and temporal savings for hospitals and patients.

Quality of Life in Healing Diabetic Wounds: Does the End Justify the Means?

The objective of this investigation was to compare the health-related quality of life (QoL) among persons participating in a randomized clinical trial of pressure-offloading modalities to heal diabetic foot wounds and diabetic neuropathic foot ulcers. In this prospective clinical trial, 63 patients with superficial noninfected, non-ischemic plantar neuropathic diabetic foot ulcers were randomized to 1 of 3 offloading modalities: total contact cast (TCC), a half-shoe, or a removable cast walker (RCW). A Short-Form 36 questionnaire (SF-36) was used to measure health-related QoL of patients before and after the 12-week study period. The overall mean baseline physical and mental summary scores for the entire population studied were 65.2 +/- 6.5 and 60.7 +/- 5.3, respectively. There were statistically significant differences between the pre- and posttreatment responses in 7 of the 8 SF-36 scales, with the nonsignificant trend in all cases signifying improvement in overall QoL. Patients' overall QoL improved regardless of the pressure-offloading device employed, although this trend was erased when the groups were dichotomized based on whether or not they healed during the study period. In conclusion, the results of this study suggest the potential moderating role of closure of a foot ulcer on the effects of the offloading modality on a patient's QoL. Specifically, the results suggest that in diabetic patients with neuropathic foot ulcers, QoL may have less to do with how an index wound is treated than it does with whether or not the wound heals.

The effectiveness of non-surgical interventions in the treatment of Charcot foot

Background Charcot neuropathic osteoarthropathy is commonly known as 'Charcot foot'. It is a serious foot complication of diabetes mellitus that can frequently lead to foot ulceration, gangrene, hospital admission and foot amputation. A multidisciplinary approach to the management of Charcot foot is taken involving medical and allied health professionals. The management approach may also differ between different countries. To date, there is no systematic review of the literature undertaken to identify the clinical effectiveness of non-operative interventions in the treatment of acute Charcot foot. Objective The objective of this review was to identify the effectiveness of non-surgical interventions with reducing lesions, ulceration, the rate of surgical intervention, reducing hospital admissions and improve the quality of life of subjects with Charcot foot. Search strategy A comprehensive search strategy was undertaken on databases available from University of South Australia from their inception to November 2006. Selection criteria Randomised controlled trials or clinical controlled trials were primarily sought. Critical appraisal of study quality and data extraction was undertaken using Joanna Briggs Institute instruments. Review Manager software was used to calculate comparative statistics. Results This review identified 11 trials and five trials were included in the review. Three trials involved the use of bisphosphonate, a pharmacological agent. Two experimental treatments were also included, evaluating palliative radiology and magnetic fields. No trials were found using immobilisation and off-loading interventions for acute Charcot foot. The overall methodological quality score of the five studies was moderate. Owing to heterogeneous data, meta-analysis could not be performed. The trials did not report on reducing lesions, ulceration, rate of surgical intervention, hospital admissions and the quality of life of subjects with Charcot foot. The trials evaluating bisphosphonates reported greater reduction in foot temperature and disease activity for intervention subjects compared with controls. Another outcome of this review indicated additional beneficial effects of bisphosphonates in reducing pain and discomfort. The trial evaluating palliative radiotherapy found no difference between groups on any outcome. A significant reduction in the amount of deformity and reduced healing time to consolidation was found after treatment in the group receiving magnetic therapy treatment. Discussion There is a lack of clinical trials evaluating the effectiveness of non-operative interventions for the management of Charcot foot (immobilisation, removable cast walkers, advice/dispensing of footwear and prescribing of orthotics). Bisphosphonates may be useful adjuncts to standard management of Charcot foot by improved healing demonstrated by a reduction in disease activity indicated by skin temperature and bone destruction. Magnetic therapy may reduce deformity, joint destruction and improve mobility. Conclusion There is a lack of evidence supporting the use of pharmacological or non-surgical interventions with reducing lesions, ulceration, rate of surgical intervention, hospital admissions and improving the quality of life of subjects with Charcot foot. Bisphosphonates may improve the healing of Charcot foot by reducing skin temperature and disease activity of Charcot foot, when applied in addition to standard interventions to control the position and shape of the foot.

The effectiveness of non-surgical interventions in the treatment of Charcot foot

Background Charcot neuropathic osteoarthropathy is commonly known as ‘Charcot foot’. It is a serious foot complication of diabetes mellitus that can frequently lead to foot ulceration, gangrene, hospital admission and foot amputation. A multidisciplinary approach to the management of Charcot foot is taken involving medical and allied health professionals. The management approach may also differ between different countries. To date, there is no systematic review of the literature undertaken to identify the clinical effectiveness of non-operative interventions in the treatment of acute Charcot foot. Objective The objective of this review was to identify the effectiveness of non-surgical interventions with reducing lesions, ulceration, the rate of surgical intervention, reducing hospital admissions and improve the quality of life of subjects with Charcot foot. Search strategy A comprehensive search strategy was undertaken on databases available from University of South Australia from their inception to November 2006. Selection criteria Randomised controlled trials or clinical controlled trials were primarily sought. Critical appraisal of study quality and data extraction was undertaken using Joanna Briggs Institute instruments. Review Manager software was used to calculate comparative statistics. Results This review identified 11 trials and five trials were included in the review. Three trials involved the use of bisphosphonate, a pharmacological agent. Two experimental treatments were also included, evaluating palliative radiology and magnetic fields. No trials were found using immobilisation and off-loading interventions for acute Charcot foot. The overall methodological quality score of the five studies was moderate. Owing to heterogeneous data, meta-analysis could not be performed. The trials did not report on reducing lesions, ulceration, rate of surgical intervention, hospital admissions and the quality of life of subjects with Charcot foot. The trials evaluating bisphosphonates reported greater reduction in foot temperature and disease activity for intervention subjects compared with controls. Another outcome of this review indicated additional beneficial effects of bisphosphonates in reducing pain and discomfort. The trial evaluating palliative radiotherapy found no difference between groups on any outcome. A significant reduction in the amount of deformity and reduced healing time to consolidation was found after treatment in the group receiving magnetic therapy treatment. Discussion There is a lack of clinical trials evaluating the effectiveness of non-operative interventions for the management of Charcot foot (immobilisation, removable cast walkers, advice/dispensing of footwear and prescribing of orthotics). Bisphosphonates may be useful adjuncts to standard management of Charcot foot by improved healing demonstrated by a reduction in disease activity indicated by skin temperature and bone destruction. Magnetic therapy may reduce deformity, joint destruction and improve mobility. Conclusion There is a lack of evidence supporting the use of pharmacological or non-surgical interventions with reducing lesions, ulceration, rate of surgical intervention, hospital admissions and improving the quality of life of subjects with Charcot foot. Bisphosphonates may improve the healing of Charcot foot by reducing skin temperature and disease activity of Charcot foot, when applied in addition to standard interventions to control the position and shape of the foot.

Nonwindowed Nonremovable Fiberglass Off-Loading Cast Versus Removable Pneumatic Cast (AircastXP Diabetic Walker) in the Treatment of Neuropathic Noninfected Plantar Ulcers

Neuropathic plantar ulcers are classical lesions secondary to diabetic polyneuropathy (1,2). The worldwide gold standard treatment is the nonremovable off-loading cast (3–5). However, the device is not widely used due to concerns related to risk factors of the off-loading cast (i.e., joint rigidity, additional ulcer formation beneath the cast, and infection of the ulcer enclosed in the cast). Our group recently demonstrated that it is possible to reduce the risk of side effects reported in literature by constructing the off-loading cast using fiberglass bandages of different rigidity. Considering the device’s scarce application because of the side effects, we conducted a controlled, randomized, prospective trial to evaluate the safety and efficacy of a removable pneumatic cast walker in comparison with a nonremovable fiberglass off-loading cast. Between January 2005 and October 2005, 60 consecutive diabetic patients with neuropathic plantar ulcers were seen and randomly assigned to two groups: group A, using an Aircast Pneumatic Walker (XP Diabetic Walker); and group B, using the fiberglass off-loading cast. All participants had peripheral neuropathy, as highlighted by insensitivity to 10 g monofilament and vibration perception threshold measured by biothesiometer at malleolus of at least 25 volts, and presented …

Early Mobilization in a Removable Cast Compared with Immobilization in a Cast after Operative Treatment of Ankle Fractures: A Prospective Randomized Study

The aim of operative treatment for ankle fractures is to allow early movement after internal fixation. The hypothesis of this study was that early mobilization would improve functional recovery in patients after surgery for ankle fractures. In a prospective randomized controlled study, 66 consecutive patients with ankle fractures that required open reduction and internal fixation (ORIF) were assigned to one of two postoperative regimens: immobilization in a nonweightbearing below-knee cast or early mobilization in a removable cast. Four patients were excluded from the study, leaving 62 for review. Patients who had early mobilization in a removable cast had higher functional scores (Olerud-Molander and AOFAS) at 9 and 12 weeks postoperatively. They also returned to work earlier (67 days) compared with those treated in nonweightbearing below-knee cast (95 days), p<0.05. There was no statistical difference in Quality of Life (SF-36 Questionnaire) at 6 months between the two groups. We had an approximately 10% postoperative infection trend (one superficial and two deep) in the early mobilization group. Despite the overall short-term benefit of early mobilization, we had three patients in the early mobilization group who had wound complications. Both the surgeon and patient should be aware of the higher risk of wound complications associated with this treatment, and thus the accelerated rehabilitation protocol should be individualized.

The effectiveness of non-surgical interventions in the treatment of Charcot foot

Charcot neuropathic osteoarthropathy is commonly known as 'Charcot foot'. It is a serious foot complication of diabetes mellitus that can frequently lead to foot ulceration, gangrene, hospital admission and foot amputation. A multidisciplinary approach to the management of Charcot foot is taken involving medical and allied health professionals. The management approach may also differ between different countries. To date, there is no systematic review of the literature undertaken to identify the clinical effectiveness of non-operative interventions in the treatment of acute Charcot foot. The objective of this review was to identify the effectiveness of non-surgical interventions with reducing lesions, ulceration, the rate of surgical intervention, reducing hospital admissions and improve the quality of life of subjects with Charcot foot. A comprehensive search strategy was undertaken on databases available from University of South Australia from their inception to November 2006. Randomised controlled trials or clinical controlled trials were primarily sought. Critical appraisal of study quality and data extraction was undertaken using Joanna Briggs Institute instruments. Review Manager software was used to calculate comparative statistics. This review identified 11 trials and five trials were included in the review. Three trials involved the use of bisphosphonate, a pharmacological agent. Two experimental treatments were also included, evaluating palliative radiology and magnetic fields. No trials were found using immobilisation and off-loading interventions for acute Charcot foot. The overall methodological quality score of the five studies was moderate. Owing to heterogeneous data, meta-analysis could not be performed.The trials did not report on reducing lesions, ulceration, rate of surgical intervention, hospital admissions and the quality of life of subjects with Charcot foot.The trials evaluating bisphosphonates reported greater reduction in foot temperature and disease activity for intervention subjects compared with controls. Another outcome of this review indicated additional beneficial effects of bisphosphonates in reducing pain and discomfort. The trial evaluating palliative radiotherapy found no difference between groups on any outcome. A significant reduction in the amount of deformity and reduced healing time to consolidation was found after treatment in the group receiving magnetic therapy treatment. There is a lack of clinical trials evaluating the effectiveness of non-operative interventions for the management of Charcot foot (immobilisation, removable cast walkers, advice/dispensing of footwear and prescribing of orthotics). Bisphosphonates may be useful adjuncts to standard management of Charcot foot by improved healing demonstrated by a reduction in disease activity indicated by skin temperature and bone destruction. Magnetic therapy may reduce deformity, joint destruction and improve mobility. There is a lack of evidence supporting the use of pharmacological or non-surgical interventions with reducing lesions, ulceration, rate of surgical intervention, hospital admissions and improving the quality of life of subjects with Charcot foot. Bisphosphonates may improve the healing of Charcot foot by reducing skin temperature and disease activity of Charcot foot, when applied in addition to standard interventions to control the position and shape of the foot.

Minimally Invasive Technique For The Management Of Communited Fracture Of The Tarsal Navicular Bone

Minimally Invasive Technique For The Management Of Communited Fracture Of The Tarsal Navicular Bone

Early exercising in removable cast compared with immobilisation in cast after operative treatment of ankle fractures: A prospective randomised study

Background: The aim of operative treatment for ankle fractures is to allow early movement after internal fixation. The hypothesis of this study was that early mobilisation facilitated by a removable cast after internal fixation of ankle fractures would improve functional recovery of patients compared with that after conventional immobilisation in a cast. Material and Methods: Sixty two patients between the age of seventeen and sixty five with ankle fractures that required operative treatment were randomly allocated to two groups : immobilisation in a non weight bearing below knee cast for six weeks or early movement in a removable cast ( at two weeks after removal of sutures ) for the following four weeks. The follow up examinations which consisted of subjective (clinical, Olerud-Molander score, AOFAS score, SF 36 ) and objective ( swelling measurement, x-ray ) evaluations were performed at two, six, nine, twelve and twenty four weeks postoperatively. Time of return to work was recorded. Results: There were no postoperative complications in the group treated with immobilisation in cast. There was one superficial wound infection treated with oral antibiotics in a patient with a previous dermatological condition around the fractured ankle in the group treated with early movement in a removable cast. Patients in group two ( early movement ) had higher functional scores at nine and twelve weeks follow up but not of statistical significance. They also return to work earlier ( 55.5 days ) compared with the ones treated in cast ( 98.7 days ). Patients treated in removable cast had higher mean SF-36 scores, but this difference was significant only for two of the eight aspects investigated. Conclusions: Early movement with the use of removable cast after removal of sutures in operated ankle fractures decrease swelling, prevent calf muscle wasting, improve functional outcome and facilitate early return to work of patients. Our findings support the use of a removable cast and early exercises in selected, compliant patients after surgery of the ankle.

Cast titanium overlay denture for a geriatric patient with a reduced vertical dimension

An older patient reporting to the dental surgery for his/her dental treatment is becoming a common occurrence. Improved oral hygiene has meant that teeth are retained for a longer time, along with the potential problems of attrition, decreased vertical dimension, temporomandibular joint discomfort/strain, and poor aesthetics. The case in question is that of a 65-year-old male patient who had severe attrition in the lower arch, temporomandibular joint pain and reduced vertical dimension. The maxillary arch had previously been restored with a fixed partial prosthesis. For restoration of the lower teeth, a removable cast titanium overlay denture was fabricated incorporating an increased vertical dimension. Porcelain facings were placed to restore the aesthetics of the anterior teeth. The titanium was cast in a semi-automatic electric arc, pressure type casting machine. A titanium overlay denture with porcelain facing on the anterior teeth may provide a means of restoring a patient's concerns regarding aesthetics and function.

The pivotal role of offloading in the management of neuropathic foot ulceration

Lower extremity amputations among persons with diabetes are generally preceded by neuropathic foot ulcerations. Healing of diabetic ulcerations in a timely manner is of central importance in any plan for amputation prevention. With sufficient vascular supply, appropriate débridement, and infection control, the primary mode of healing a diabetic neuropathic foot ulcer is pressure dispersion. The total contact cast has been deemed by many to be the gold standard in offloading; however, modification of a standard removable cast walker to ensure patient compliance may be as efficacious in healing diabetic foot ulcers as the total contact cast. Combining an effective, easy to use offloading device that ensures patient compliance with advanced wound healing modalities may form a formidable team in healing ulcers and potentially averting lower limb amputations.

A Review of the Biomechanics of the Diabetic Foot

In general, diabetic foot ulcers result from abnormal mechanical loading of the foot, such as repetitive moderate pressure applied to the plantar aspect of the foot while walking. Diabetic peripheral neuropathy causes changes in foot structure, affecting foot function and subsequently leading to increased plantar foot pressure, which is a predictive risk factor for the development of diabetic foot ulceration. Prevention of diabetic foot ulceration is possible by early identification of the insensitive foot, therefore a foot "at risk," and by protecting the foot from abnormal biomechanical loading. Abnormal foot pressures can be reduced using several different approaches, including callus debridement, prescription of special footwear, injection of liquid silicone, Achilles tendon lengthening, and so forth. Off-loading of the diabetic wound is a key factor in successful wound healing, as it is associated with reduced inflammatory and accelerated repair processes. Pressure relief can be achieved using various off-loading modalities including accommodative dressing, walking splints, ankle-foot orthosis, total contact cast, and removable and irremovable cast walkers.

Acute Foot Injury???Professional Ballet Dancer

HISTORY 36 year-old female professional ballet dancer presented with acute onset of proximal plantar foot pain. Prior to injury she had a 3-day history of plantar foot pain with increased symptoms in the morning. She has not had previous treatment or injections. This pain dissipated as morning activities increased. The pain was located in the region of the distal plantar heel. During a routine workout she felt a tear and severe pain as she attempted a jump. After this event, she was unable to continue dancing and had pain with weight bearing and any ankle motion. PHYSICAL EXAMINATION Examination revealed a fullness and tenderness at the proximal insertion of the medial plantar fascia. Range of motion of the ankle was painful and she was unable to bear weight with a single leg stance. There was moderate pain with resisted plantar flexion and pain with forced dorsiflexion. DIFFERENTIAL DIAGNOSIS Plantar fasciitis Acute rupture of plantar fascia Avulsion fracture of the calcaneous TEST AND RESULTS MR imaging: Revealed a complete tear of the medial plantar fascia at its origin from the calcaneous The lateral plantar fascia was edematous without evidence of a tear. FINAL WORKING DIAGNOSIS Acute rupture of the plantar fasciaFigureTREATMENT AND OUTCOMES Non-steroidal anti-inflammatory medications Non-weight bearing for 2 weeks in a removable cast boot Physical Therapy consisting of gentle range of motion, icing and deep massage Protected weight bearing with heel cup for after decrease in pain symptoms Advancement to barre work in high-top shoe after resolution of symptoms, with avoidance of jumping for 2 additional weeks