Walking Boot Research Articles

Effect of CAM boot immobilization on weightbearing stability in syndesmotic injuries

Category: Trauma Introduction/Purpose: Ankle injuries are one of the most frequent traumas of the lower limb. They typically involve the lower lateral ligaments of the ankle, but the syndesmosis is also affected in up to 18% of cases. The degree of instability of syndesmotic joint depends on which ligaments are affected. Adequate management of syndesmotic injuries is crucial to avoid long term complications. The primary goal of our study was to evaluate the effect of simulated weightbearing on syndesmotic instability resulting from isolated AiTFL injury and from combined AiTFL/IOL injuries. The secondary goal was to evaluate the effect of a controlled ankle motion walking boot on syndesmosis stability following injury. We hypothesized that the CAM boot would prevent significant instability even in two ligaments injuries. Methods: Ten cadaveric specimens were dissected to expose the syndesmosis to create progressive iatrogenic syndesmosis ruptures. Uninjured syndesmoses were compared to isolated AiTFL and combined AiTFL/IOL ruptures. The specimens were fitted in a custom-made device to allow stabilization of the leg and apply a reproducible axial load (AL) of 750 N, equivalent to the weight of a 168-pound person. For each specimen and injury pattern, CT-scan images were obtained with and without AL, and with a CAM boot under AL. Distal tibio-fibular relationship was evaluated in three planes using a previously validated measurement system developed on CT. Wilcoxon tests for paired samples and non-parametric data were done to compare the different conditions. Results: For our first objective, when comparing ankles with isolated AiTFL to combined AiTFL/IOL rupture with and without AL, the only significant difference was an increase in internal rotation between the incisura and a line drawn in the axis of the fibula. Even with minimal statistical differences, it appears that axial loading does not impact syndesmotic stability apart from a slight increase in internal rotation with a single or two-ligament injury. As for our second end point, with the CAM orthopedic boot, no significant widening of the syndesmosis happened when either one or both ligaments were sectioned, in an axial loading state. We therefore confirmed our hypothesis that even with two syndesmotic ligament injuries, axial loading in a CAM boot does not affect distal tibio-fibular anatomy. Conclusion: This study reveals that weight bearing without rotational force does not affect the stability of the syndesmosis. Incomplete syndesmotic injuries can likely be treated with nonoperative treatment in a CAM boot and weight bearing as tolerated. Further clinical studies are needed to confirm these findings.

Functional bracing treatment for stable type B ankle fractures

BackgroundIn general, stable type B ankle fractures are treated conservatively with cast immobilization or a walking boot during six weeks. Some disadvantages of casting are joint stiffness, muscle wasting and lack of comfort. This study was designed to evaluate whether functional treatment with a removable brace is a safe and more comfortable alternative. Material and methodsRandomized controlled trial. In the period March 2013 - May 2015, 44 patients visiting the emergency department due to a stable type B ankle fracture were included. During the first week both groups received a splint. After one week the patients were randomized: one group received a cast, the other a removable brace. For outcome Olerud & Molander Ankle Score, Visual Analogue Score for comfort and pain, American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle score questionnaire, EuroQol-5D and range of motion were used. Results44 patients participated (21 cast, 23 brace). There were no differences in baseline characteristics. After 6 weeks, VAS for comfort (cast vs brace; 5.74 vs 7.21; p = 0.02) and total range of motion (40° vs 49°; p = 0.00) showed significant differences in favour of the brace. VAS pain (3.15 vs 2.05; p = 0.16), OMA-score (51.75 vs 61.32; p = 0.22) en EuroQoL-5D (7.26 vs 6.74; p = 0.33) did not show significant differences. Week 52 showed no significant differences at OMA-score (89.29 vs 96.18; p = 0.16), EuroQoL-5D (6.00 vs 5.35; p = 0.15), VAS pain (1.07 vs 0.82; p = 0.69) and AAOS score (91.71 vs 96.06; p = 0.21). No complications occurred in both groups. ConclusionFunctional bracing showed significant differences for the VAS comfort score and range of motion at 6 weeks compared to casting. After a year no significant differences were found. Treatment with a brace is a safe and more comfortable option for stable type B ankle fractures.

A Prospective Cohort Study of Symptomatic Venous Thromboembolic Events in Foot and Ankle Trauma: The Need for Stratification in Thromboprophylaxis?

The incidence of venous thromboembolic (VTE) events (deep vein thrombophlebitis [DVT] or pulmonary embolism [PE]) in foot and ankle trauma has been low, and the risk/benefit ratio associated with chemoprophylaxis is controversial. We compared the 90-day incidence of VTE events in 3 cohorts: group 1, tendo-Achillis (TA) ruptures managed with full weightbearing in a walker boot; group 2, ankle fractures immobilized non-weightbearing in a below-the-knee cast; and group 3, ankle fractures managed surgically, followed by non-weightbearing in a below-the-knee cast. Data were extracted from 2 prospectively collected trust databases for acute TA ruptures and ankle fractures. VTE risk was assessed using a U.K. national assessment tool. Chemoprophylaxis was prescribed for high-risk patients. The 90-day incidence of symptomatic VTE events was drawn from a trust-wide radiology database. In group 1 (n = 291), the incidence of VTE events was 4.8% (11 [3.8%] DVT, 3 [1.0%] PE) at a mean of 16.1 ± 6.8 days. In group 2 (n = 227), the incidence of VTE events was 2.2% (5 [2.2%] DVT) at a mean of 33.4 ± 11.3 days. In group 3 (n = 199), the incidence of VTE events was 3.0% (5 [2.5%] DVT, 1 [0.5%] PE) at a mean of 37.2 ± 14.2 days. Patients with symptomatic VTE events presented significantly earlier after acute TA rupture compared with after ankle fracture (p = .002). We found the overall incidence of VTE events in foot and ankle trauma was low, with a relatively greater incidence of symptomatic VTE events, which occurred earlier, in acute TA ruptures compared with ankle fractures.

City Profile: Sligo, Ireland

W hen I pulled into Sligo on the morning bus with a dog-eared copy of W. B. Yeats’s Collected Poems, I carried two wishes: first, that it would stop raining. And second, that I might uncover some of the vital, inspiring force behind my favorite poet. One gets over the rain. Located on the coastal edge of County Sligo in the northwest of Ireland, Sligo rests on the neck of land between Sligo Bay and the placid Lough Gill. Riverside restaurants, shops, and lively pubs line the town center, where the swinging doors of little cafés disclose the smell of black currant scones or the flash of jam jars and bottles of cordial. Visitors’ maps lead to abbeys, churches, and other historical sites around town, but somehow, people seem to gravitate toward Wine Street, where the Yeats Memorial Building stands. Lovers of Irish poetry have good reason to venture to a less-trafficked town like Sligo. Yeats’s early work draws deeply from the natural features and fairy stories of the area where he spent much of his youth, and his footprints linger. With a car, a bicycle, or a sturdy pair of walking boots, one can retrace the journey of “The Stolen Child” through the deciduous canopy of old Slishwood to the rustling waterfall of Glen-Car, where the fairies swing from fern fronds. Bus and ferry can bring you to the famous lake isle of Innisfree that hummed peacefully in Yeats’s memory amid the bustle of London, or to the Salley Gardens where he would rendezvous with Maud Gonne, ever aloof. The more solemn-minded make their way to the cemetery where Yeats lies interred “Under bare Ben Bulben’s head / In Drumcliff churchyard” and ruminate on the lines cut into his simple headstone. Despite the area’s many draws, travelers from too far afield are regarded as something of a pleasant surprise. Tours are more likely to be filled with visitors from another county than curious continentals or pond-hopping Americans. Let slip a foreign accent and you may find yourself caught up in a chat with a lifelong resident. Should your dialogue take a turn toward poetry, you may discover one of Sligo’s greatest charms: here, literature never quite becomes history. Sligo is a place of poetry without pomp. Verse is scrawled on the walls, written into folk songs, and etched into the memories of those raised with rhymes on their tongues. Yeats’s legacy is borne proudly and revisited frequently. One exemplar of this (and for me, one of the town’s great treasures) is the Hamilton Gallery, which, in addition to exhibiting artwork from a vast range of contemporary Irish artists, holds an annual invitational exhibition reflecting on some aspect of Yeats’s work. Each of these special shows is a culmination of the unique kind of presence with which Sligo is gifted—one that allows its inhabitants, and perhaps its pilgrims, to poignantly reenvision the life and work of W. B. Yeats. Grant Schatzman is a WLT intern and a writer, editor, and student at the University of Oklahoma. Notebook city profile Sligo, Ireland by Grant Schatzman LEFT PHOTO: DAVE GUNN. RIGHT PHOTO: KEITH EWING left Sligo’s River Garavogue. right Yeats’s grave in St. Columba’s churchyard. WORLDLIT.ORG 5 ...

City Profile: Sligo, Ireland

W hen I pulled into Sligo on the morning bus with a dog-eared copy of W. B. Yeats’s Collected Poems, I carried two wishes: first, that it would stop raining. And second, that I might uncover some of the vital, inspiring force behind my favorite poet. One gets over the rain. Located on the coastal edge of County Sligo in the northwest of Ireland, Sligo rests on the neck of land between Sligo Bay and the placid Lough Gill. Riverside restaurants, shops, and lively pubs line the town center, where the swinging doors of little cafés disclose the smell of black currant scones or the flash of jam jars and bottles of cordial. Visitors’ maps lead to abbeys, churches, and other historical sites around town, but somehow, people seem to gravitate toward Wine Street, where the Yeats Memorial Building stands. Lovers of Irish poetry have good reason to venture to a less-trafficked town like Sligo. Yeats’s early work draws deeply from the natural features and fairy stories of the area where he spent much of his youth, and his footprints linger. With a car, a bicycle, or a sturdy pair of walking boots, one can retrace the journey of “The Stolen Child” through the deciduous canopy of old Slishwood to the rustling waterfall of Glen-Car, where the fairies swing from fern fronds. Bus and ferry can bring you to the famous lake isle of Innisfree that hummed peacefully in Yeats’s memory amid the bustle of London, or to the Salley Gardens where he would rendezvous with Maud Gonne, ever aloof. The more solemn-minded make their way to the cemetery where Yeats lies interred “Under bare Ben Bulben’s head / In Drumcliff churchyard” and ruminate on the lines cut into his simple headstone. Despite the area’s many draws, travelers from too far afield are regarded as something of a pleasant surprise. Tours are more likely to be filled with visitors from another county than curious continentals or pond-hopping Americans. Let slip a foreign accent and you may find yourself caught up in a chat with a lifelong resident. Should your dialogue take a turn toward poetry, you may discover one of Sligo’s greatest charms: here, literature never quite becomes history. Sligo is a place of poetry without pomp. Verse is scrawled on the walls, written into folk songs, and etched into the memories of those raised with rhymes on their tongues. Yeats’s legacy is borne proudly and revisited frequently. One exemplar of this (and for me, one of the town’s great treasures) is the Hamilton Gallery, which, in addition to exhibiting artwork from a vast range of contemporary Irish artists, holds an annual invitational exhibition reflecting on some aspect of Yeats’s work. Each of these special shows is a culmination of the unique kind of presence with which Sligo is gifted—one that allows its inhabitants, and perhaps its pilgrims, to poignantly reenvision the life and work of W. B. Yeats. Grant Schatzman is a WLT intern and a writer, editor, and student at the University of Oklahoma. Notebook city profile Sligo, Ireland by Grant Schatzman LEFT PHOTO: DAVE GUNN. RIGHT PHOTO: KEITH EWING left Sligo’s River Garavogue. right Yeats’s grave in St. Columba’s churchyard. WORLDLIT.ORG 5 ...

3D gait analysis with and without an orthopedic walking boot

IntroductionOrthopedic walking boots have been widely used in place of traditional fiberglass casts for a variety of orthopedic injuries and post-surgical interventions. These walking boots create a leg length discrepancy (LLD). LLD has been shown to alter the kinematics and kinetics of gait and are associated with lumbar and lower limb conditions such as: foot over pronation, low back pain, scoliosis, and osteoarthritis of the hip and knee joints. Past gait analyses research with orthopedic boots is limited to findings on the ipsilateral limb. Thus, the purpose of the study was to examine bilateral gait kinematics & kinetics with and without a walking boot. MethodsForty healthy participants (m=20, f=20, age 20.7±1.8 yrs., ht. 171.6±9.5cm, wt. 73.2±11.0kg, BMI 24.8±3.2) volunteered. An eight camera Vicon Motion Capture System with PIG model and two AMTI force plates were utilized to record the walking trial conditions: (1) bilateral tennis shoes (2) boot on right foot, tennis shoe on left foot (3) boot on right foot, barefoot on left foot. Data were processed in Nexus 2.2.3 and exported to Visual 3D for analysis. ResultsWhen wearing the boot, there were significant differences in most joint angles and moments, with larger effects on long limb. ConclusionThe walking boot alters the gait in the same way as those with existing LLD, putting them at risk for development of secondary knee, hip, and low back pain during treatment protocol.

Hallux Motion

Category: Bunion, Trauma, Other Introduction/Purpose: Immobilization is required for management of acute and chronic pathologic states of the hallux metatarsophalangeal (MTP) joint. Traditionally, this was performed using physician applied custom splint or cast and achieved a high degree of immobilization. Braces and orthotics are becoming less expensive and have several advantages, such as light weight and convenience in removal. However, this may come at the expense of ability to restrict movement. We hypothesize that generic braces will provide as much immobilization as custom applied plaster splints. Methods: Healthy volunteers were instrumented with electromagnetic sensors over bony prominences of the right foot. Range of motion exercises and activities of daily living were performed without an immobilization device. The same procedure was repeated with each of three immobilization devices: a post-operative shoe, a walking boot, and a custom applied plaster splint. Position and angular data were collected to determine range of motion primarily of the hallux MTP joint. This study was approved by the hospital IRB Results: Compared to baseline, all three immobilization devices significantly reduced range of motion at the MTP joint in non- weight bearing with the ankle in dorsiflexion and plantarflexion (p<0.05). There was no significant difference detected between the devices. There was no significant difference in hallux motion during the standing exercise in any of the immobilization devices compared to baseline. During stance phase of gait, all three devices reduced range of motion at the MTP joint compared to baseline (p<0.05), though there was no statistically significant difference between devices. Conclusion: Consistent with the hypothesis, data from this study show that all both generic devices and the physician applied splint reduced range of motion compared to baseline. Unfortunately, the study was not powered enough to detect significant differences between the devices, though there was a trend towards the walking boot providing more immobilization.

Early Protected Weightbearing for Acute Ruptures of the Achilles Tendon: Do Commonly Used Orthoses Produce the Required Equinus?

Conservative “functional” management of acute Achilles tendon ruptures has become increasingly popular. Critical to this is the use of the walking orthosis, which positions the ankle in equinus to allow for early weightbearing. Our aim was to test whether 2 common orthoses achieved a satisfactory equinus position. A total of 11 sequentially treated Achilles tendon ruptures were assigned to either a fixed angle walking boot with wedges (FAWW) or an adjustable external equinus-corrected brace (EEB). The lateral radiographs of the cast immobilized tendons showed a mean tibiotalar angle (TTA) of 56° (range 54° to 57°) and a mean tibio-first metatarsal angle (1MTA) of 74° (range 62° to 85°). The FAWW resulted in a mean TTA of 28° (range 15° to 35°) and 1MTA of 37° (range 30° to 45°). The EEB resulted in a TTA of 48° (range 43° to 45°) and 1MTA of 54° (range 47° to 57°). Ankle equinus was significantly greater with the EEB than with the FAWW (p < .05) and similar to that with an equinus cast. The use of wedges produced an equinus appearance through the midfoot but not at the ankle. We express caution in the use of the FAWW because it is unlikely to achieve sufficient ankle equinus to shorten the Achilles tendon.

Aseptic loosening of total ankle replacement : One-stage revision ankle arthroplasty

To revise one or both loosened prosthesis components, to achieve postoperative pain relief, and preserve ankle range of motion. Aseptic loosening of the tibial and/or talar ankle prosthesis components without substantial bone defect of the tibial or talar bone stock. General surgical or anesthesiological risks, infections, critical soft tissue conditions, nonmanageable hindfoot instability, neurovascular impairment of the lower extremity, neuroarthropathy (e. g. Charcot arthropathy), substantial nonreconstructable osseous defects with or without cysts on the tibial and/or talar side, non-compliance, patients with primary total ankle replacement (TAR) using intramedullary fixation (stem fixation), patients with severely reduced bone quality, insulin-dependent diabetes mellitus, smoking, unrealistic patient expectations, patients with high activity in sports. Exposure of the ankle joint using the previous incision (anterior or lateral transfibular approach). Mobilization and removal of loosened prosthesis component. Careful debridement of bone stock at bone-prosthesis interface. Determination of prosthesis component size. Implantation of definitive prosthesis components. Wound closure in layers. Asoft wound dressing is used. Thromboprophylaxis is recommended. Patient mobilization starts at postoperative day1 with 15 kg partial weight bearing using astabilizing walking boot or cast for 6weeks. Following clinical and radiographic follow-up at 6weeks, full weight bearing is initiated gradually. Between January 2007 and December 2012 aone-stage revision TAR was performed in 14patients with amean age of 52.7± 12.0years (29.8-70.5years). The indication for revision surgery was aseptic loosening of one or both prosthesis components. The mean time between the initial TAR and revision surgery was 5.9± 2.9years (2.0-11.5years). In 2patients atibiotalocalcaneal arthrodesis was performed due to painful aseptic loosening of revision TAR. In all patients asignificant pain relief was observed.

Ciprofloxacin Induced Achilles Tendinopathy

HISTORY: 26 year old college graduate student with past medical history of a kidney stone had painful urination and increased frequency over several days. He was seen by internist at student health center, prescribed Ciprofloxacin for 14 days for acute bacterial prostatitis. Two months later he developed right Achilles tendon pain which had started insidiously upon awakening one morning, with no inciting event except for taking Ciprofloxacin 6 weeks earlier. PHYSICAL EXAMINATION: Swelling of the of posterior ankle noted. Tenderness to palpation at the insertion site of a tight Achilles tendon was appreciated. DIFFERENTIAL DIAGNOSIS: 1. Ciprofloxacin induced Achilles tendinopathy 2. Idiopathic Achilles tendinopathy 3. Postraumatic Achilles tendinopathy TEST AND RESULTS: 1. Ankle ultrasonography: Thickening and swelling of Achilles tendon. 2. Ankle X-tray: No bony abnormalities. FINAL WORKING DIAGNOSIS: Ciprofloxacin Induced Achilles Tendinopathy TREATMENT AND OUTCOMES: 1. Walking boot 2. NSAIDs 3. Physical therapy. Patient has recovered after six month of treatment.

A Rare Cause of Foot Pain in an Adolescent Male Multisport Athlete

HISTORY: A 13 year old male football, basketball, and baseball athlete presented to sports medicine clinic with a 3 month history of non-traumatic exertional right lateral foot pain. He reported 8/10 pain with strenuous activities, such as running and jumping. He had no pain with walking. He reported aching discomfort in the morning upon waking. He denied numbness, tingling, or abnormal sensation. PHYSICAL EXAMINATION: There was no significant deformity. He was able to walk with a non-antalgic gait. There was tenderness to palpation over the lateral base of the 5th metatarsal. Range of motion of the foot and ankle was normal. There was normal strength upon manual muscle testing, but resisted ankle eversion reproduced pain. He was neurovascularly intact. DIFFERENTIAL DIAGNOSIS: 1. Metaphyseal-Diaphyseal (Jones) Fracture 2. Fifth Metatarsal Stress Fracture 3. Traction Apophysitis (Iselin’s Disease) 4. Insertional Peroneal Tendinopathy 5. Avulsion Fracture TESTS AND RESULTS: - Right foot radiograph: Well-corticated bone fragment proximal and perpendicularly-oriented to the base of the 5th metatarsal, representing an accessory ossicle (os vesalianum) versus ununited fracture. No evidence of acute fracture and normal-appearing apophysis. - Right foot MRI: Osseous body at base of the 5th metatarsal with irregular margins, hyperintense T2 fibrous union, and internal edema of the ossicle and adjacent proximal metatarsal, favored to represent a symptomatic os vesalianum. No increased apophyseal distraction. FINAL WORKING DIAGNOSIS: Symptomatic Accessory Os Vesalianum TREATMENT AND OUTCOMES: 1. Immobilize in a walker boot for 6-8 weeks. 2. Physical therapy after immobilization, with emphasis on peroneal muscle strengthening and range of motion. 3. If complete resolution of symptoms, may gradually return to sport as tolerated. If symptoms persist, consider surgical excision.

Foot Injury in a Recreational Runner

Foot Injury in a Recreational Runner Ashkan Alkhamisi, MD, Glenn G. Shi, MD, and George G.A. Pujalte, MD, FACSM HISTORY: A 37-year-old, healthy, young female presented with 5 weeks of left foot pain. She denied any major trauma or precipitating event, but did recall doing holiday shopping for 10 hours straight a few days prior to experiencing symptoms. Patient stated that she used to wear heels all the time at work as a school-teacher. She reported numbness and tenderness over the plantar aspect of the first metatarsophalangeal joint. She wore a metatarsal pad and took ibuprofen with no relief of symptoms. The pain was exacerbated with weightbearing. PHYSICAL EXAMINATION: Left foot: No tenderness to palpation of the hindfoot or midfoot. Pain was elicited with passive dorsiflexion and plantarflexion of first metatarsophalangeal (MTP) joint. Tenderness to palpation along the lateral aspect of the first MTP joint, with no erythema or swelling. Sensation was intact. DIFFERENTIAL DIAGNOSES: 1. Sesamoid osteoarthritis 2. Sesamoid stress fracture 3. Sesamoid dislocation 4. Sesamoiditis TEST AND RESULTS: Left foot, standing, 3 views: Fragmentation of the left lateral hallux sesamoid, with small surrounding foci of mineralization. Remainder of osseous structures were intact. No focal soft tissue swelling. FINAL DIAGNOSIS: Left lateral (fibular-sided) non-union sesamoid fracture TREATMENTS AND OUTCOMES: 1. Immobilization within a boot, with non-weightbearing status for 6 weeks 2. At 2 months post-injury, she continued to have pain and wanted to wear the walking boot for another 1-2 months 3. Repeat radiographs at 3 and 4 months post-injury showed continued non-union of the lateral sesamoid bone. 4. Orthopedic referral was made at 4 months post-injury and she decided to proceed with a left lateral sesamoidectomy with immobilization within a boot for 4 weeks. 5. At 4 months post-operatively, she was able to run with no pain and good range of motion of her left first MTP joint.Figure

Benign or Malignant: A Case Report of Multifocal Epithelioid Hemangioma of Fibula

Case Presentations: A 63-year-old female with no significant prior trauma and relevant past medical history presented with a 2-month history of severe, persistent, gradually worsening, sharp and non-radiating pain over her left distal fibula. Physical examination revealed extreme tenderness to palpation over the lateral distal fibula. There was soft tissue prominence over the mid to lower third of the fibula. Results: Left lower leg radiographs depicted two ill-defined osteolytic destructive lesions measuring 29 and 37 mm in length in the fibular diaphysis. A pathologic fracture was present through the distal lesion. A laboratory test, including serum protein electrophoresis, alkaline phosphatase and basic metabolic profile, was ordered to evaluate for multiple myeloma. CT scans of the chest and abdomen were obtained to evaluate for primary malignancy or any evidence of metastatic disease. The results of these tests were unremarkable. Image-guided biopsy of the lesions was performed and revealed epithelioid hemangioma (EH). The patient was initially managed with a walker boot. At the 2-month follow-up, an additional third smaller lesion was detected along with an interval increase in size of the two previously seen lesions. The patient proceed with preoperative embolization followed by surgical curettage and open reduction and internal fixation. Angiogram was done and tumor feeding artery was identified but tumor embolization was unsuccessful. The patient underwent fibular bone lesion curettage, PRO-DENSE bone grafting and open reduction and internal fixation with the left fibular diaphyseal plate. Radiographs revealed continued healing with bone graft incorporation at 1.5-, 3- and 7-month follow-ups. The patient was permitted to return to all activities without restriction 1.5 months after the surgery. Conclusions: EH is an uncommon, slow-growing vascular tumor that generally presents on the skin and the subcutaneous soft tissues of the head, with osseous EHs being rare. Although osseous EHs can present as multifocal lesions, the majority of bony EHs are solitary and arise in the diaphysis or metaphysis of long tubular bones, with a predilection for the lower extremity. Radiographically, EH may present as well-defined lytic lesions with sclerotic margins or mixed lytic and sclerotic lesions. These lesions are often located eccentrically and may demonstrate a disrupted or intact cortex.

Current Trends in the Management of Lateral Ankle Sprain in the United States.

To characterize trends in the acute management (within 30 days) after lateral ankle sprain (LAS) in the United States. Descriptive epidemiology study. Of note, 825 718 ankle sprain patients were identified; 96.2% were patients with LAS. Seven percent had an associated fracture and were excluded from the remaining analysis. Primary and tertiary care settings. We queried a database of national health insurance records for 2007 to 2011 by ICD-9 codes for patients with LAS while excluding medial and syndesmotic sprains and any LAS with an associated foot or ankle fracture. The percentage of patients to receive specific diagnostic imaging, orthopedic devices, or physical therapy treatments within 30 days of the LAS diagnosis and the associated costs. Over two-thirds of patients with LAS without an associated fracture received radiographs, 9% received an ankle brace, 8.1% received a walking boot, 6.5% were splinted, and 4.8% were prescribed crutches. Only 6.8% received physical therapy within 30 days of their LAS diagnosis, 94.1% of which performed therapeutic exercise, 52.3% received manual therapy, and 50.2% received modalities. The annual cost associated with physician visits, diagnostic imaging, orthopedic devices, and physical therapy was 152 million USD, 81.5% was from physician evaluations, 7.9% from physical therapy, 7.2% from diagnostic imaging, and 3.4% from orthopedic devices. Most patients with LAS do not receive supervised rehabilitation. The small proportion of patients with LAS to receive physical therapy get rehabilitation prescribed in accordance with clinical practice guidelines. The majority (>80%) of the LAS financial burden is associated with physician evaluations.

Surgery for Type B Ankle Fracture Treatment: a Combined Randomised and Observational Study (CROSSBAT)

BackgroundIsolated type B ankle fractures with no injury to the medial side are the most common type of ankle fracture.ObjectiveThis study aimed to determine if surgery is superior to non-surgical...

Asisstance Arthroscopy in Juvenile Tillaux Fractures

Introduction:Juvenile Tillaux Fracture is an isolated fracture of the lateral portion of the distal tibial epiphysis, considered SALTER-HARRIS fracture type 3, wherein the fragment is moved by the anterolateral ligament anterior inferior tibiofibular. They occur at the beginning of the 2nd decade of life and are caused by a force external rotation. The pattern of injury is considered a result of the closing sequence of the distal tibial physis, which usually closes around 15 years of age in girls and 17 in boys, this process usually takes about 18 months, occurring first in the central area of the physis, extending medially and finally to side, being this epiphyseal portion which is open at the time of the vulnerable to fracture injury in this age group. The curriculum includes RX, and TAC, being more sensitive to detect fragments of 2 or more mm of travel, but may overestimate the true displacement. The non-displaced fracture can be treated with cast immobilization and displaced with closed reduction (plantar flexion external rotation in the pronated foot and direct pressure on the anterolateral epiphysis). An equal displacement or > 2 mm of the articular surface is indication of open reduction and percutaneous fixation, because it may increase the risk of osteoarthritis in the future.Objective:Presentation of a case Juvenile Tillaux Fractures with surgical resolution under arthroscopic assistance.Methods:Male patient 14 years old who suffered indirect trauma left ankle during practice sports (rugby) in September 2015, 48 hours of evolution. After performing X-rays and scans one left Salter Harris type III at the level of distal tibial epiphysis (Tillaux fracture) ankle fracture was diagnosed. It had a greater than 2 mm displacement. As a reduction treatment and percutaneous osteosynthesis with more osteodesis screw with arthroscopic assistance and fluoroscopy was performed. After surgery a long leg cast was placed for three weeks, continuing with three other short boot. By the third week the plug removal. After the sixth week began with partial load with Walker boot for a month and later full charge.Results:Fracture healing was evident in the eighth week. Now in his eighth postoperative month and has an excellent performance according to the AOFAS score of 96 points, with no pain, full range of motion and return to sport after 4th month.Discussion:There are reports such as A. Kaya et.al (2007) with excellent results (AOFAS 99.3) in a series of 10 patients treated by open reduction and internal fixation and in other hand A. Panagopoulus, L.van Kiekerk (2007) reports excellent results (AOFAS 100) in patients treated under arthroscopic assistance. Assistance arthroscopy in Tillaux fractures allows a reduction more accurate than that provided by percutaneous techniques fluoroscopy guided only by avoiding the problems associated with open techniques (lesion of the superficial peroneal nerve and necrosis of the fragment). It also allows patients to an early return to activities with a lower risk of stiffness and secondary osteoarthritis due to the reduction achieved under direct arthroscopic visualization.

Outcomes of prolotherapy for intra-tendinous Achilles tears: a case series.

The intra-tendinous tear is a new pathology that is defined as a discontinuity of fibres situated entirely within the tendon. Prolotherapy involves injecting an irritant, such as hyperosmolar dextrose, to stimulate a tissue healing response and ultimately reduce pain. 43 consecutive patients diagnosed with an intra-tendinous tear were included (27 males: 16 females, mean (SD) age 41 (11.3). Patients were injected with 0.4ml-1.5ml (mean 0.8ml) of 50% dextrose and 0.5% marcaine mixed in a 1:1 ratio. A 4-6 week period of walking boot immobilisation was followed by progressive rehabilitation (6-8 weeks). Outcomes were assessed with a VISA-A questionnaire at baseline, 3 months and a mean 12.6 (7.0) months post-treatment. Ultrasound scans were conducted before treatment and 5.2 (2.3) weeks later to assess sonographic changes. 30 patients (70%) responded with VISA-A scores increasing by 31 (30.5) points after 3 months (f=0.62, p<0.05) and by 40 (29.3) points after 12.60 (7.0) months (f=0.87, p<0.05). After 5.2 (2.3) weeks, echogenicity was significantly reduced (p<0.05) and 27% of tears were no longer detectable. No significant differences were observed in remaining tears with respect to tear size, tendon thickness or neovascularisation. Treatment resulted in clinically significant improvements and controlled trials are warranted. IV.

Shorter recovery can be achieved from using walking boot after operative treatment of an ankle fracture

Background/ObjectiveAnkle fractures, even if treated surgically, usually take a long time to heal. For all patients with ankle fracture, immobilisation is a critical part of treatment. Short-leg walking boots (WBs) have been reported to be an effective alternative to plaster casts (PCs) that could shorten this postoperative recuperative period. The aim of this study was to compare the functional recovery of a conventional PC with that of a WB after surgery for ankle fractures. MethodsForty-seven patients (mean age, 53.9±12 years) who had undergone surgical operation for an unstable ankle fracture from January 2008 to October 2014 were reviewed retrospectively. Either a PC or a WB was prescribed postoperatively, with 25 patients and 22 patients, respectively. The time that it took the patient to stand unipedal on the affected side after allowing full-weight bear and to walk without crutches were used for assessment of functional recovery. The prevalence of postoperative loss of reduction and nonunion was also reviewed. ResultsBoth the time of being able to stand unipedal on the injured side and to walk without crutches were significantly shorter in patients using WBs (WB, 2.6 weeks; PC, 4.5 weeks, p=0.01; WB, 1.4 weeks; PC, 3.1 weeks, p=0.03). There were no patients with loss of reduction or nonunion. ConclusionPatients who used WBs showed a significantly faster recovery. WBs have an adjustable heel lift that allows users to change the ankle position slightly plantarflexed that helps walking in a postoperative swollen ankle. WBs are easy to slip on, and it is easy to adjust the ankle position in conformity with swelling so that the least painful position could be maintained during walking. WBs have good fixity to allow immediate weight-bearing postoperatively, and there were no cases with loss of reduction postoperatively. The Rocker bottom design minimises the sagittal plane motion in the specific joint of the foot, which also facilitates the course of recuperation. An ankle fracture fixed appropriately endures loading when a WB is used. The WB treatment results in faster functional recovery, allowing the patients to return to normal activity at a faster rate.

Comparison of Early Functional Rehabilitation and Cast Immobilization after Minimally Invasive Repair of an Acute Achilles Tendon Rupture

Category: Hindfoot Introduction/Purpose: The optimal treatment for acute Achilles tendon ruptures is still a subject of debate. Operative repair of an acute Achilles tendon rupture (ATR) reduces the risk of re-rupture and has therefore gained popularity as a standard treatment for ATR. There is ongoing controversy over the best surgical technique and postoperative treatment. The purpose of the present study was to compare the outcomes of patients with an acute Achilles tendon rupture treated with minimally invasive repair and early functional rehabilitation with the outcomes of similar patients treated with cast immobilization. Methods: 41 patients were enrolled in this study. All included patients underwent minimally invasive surgery, after which a below-knee splint with the foot in 120 degrees of plantar flexion was applied for the first week. Patients were then divided to the cast immobilization group (IG) or to the functional group (FG). The ankle in the IG was immobilized in a fiberglass cast in 110 degrees of plantarflexion during next 1 week and in 100 degrees in next 1 week and neutral position with full weightbearing in weeks 3 to 4. From the second week, patients in the FG were mobilized, full weightbearing, in a CAM Walker boot with weekly removing heel wedges. (first wedge removed at 2 weeks, second wedge removed at 3 weeks, third at 4weeks) Data were collected during the outpatient checks at 6 weeks; 3 and 6 months; and 1 year. Results: There was no clinically important difference between groups with regard to heel height, range of motion, return to work or sports, calf circumference, VAS, AOFAS, ATRS except ROM difference at 6weeks and heel height at 3 months. Rerupture occurred in one patient in each group. Conclusion: The minimally invasive repair of ATR was a safe and reliable technique with good results. Early mobilization and weightbearing seemed to be as safe as more traditional postoperative immobilization with similar functional result and complications.

Ethical Considerations Related to Impaired Driving After Orthopaedic Injuries.

A 35-year-old man sustained a right trimalleolar ankle fracture after a fall. He was treated uneventfully with open reduction and internal fixation. At his first postoperative appointment, he was transitioned out of a splint to a controlled ankle movement walking boot and was instructed to remain non-weight-bearing. The patient expressed relief to be out of the splint because he could now return to his job as a commercial bus driver. When the physician explained to the patient that he was not yet ready to drive, the patient reported that he had been driving with the splint in place and needed to work for the income. Despite the physician’s insistence that it would be unsafe to drive, the patient was emphatic that he must return to work. The physician understood the patient’s desire to drive, but was worried about the patient’s safety and the safety of others. Impaired driving is a major cause of morbidity and mortality in the United States. Accidents involving alcohol-impaired drivers were responsible for 10,076 deaths in 20131. Although driving under the influence of psychoactive substances constitutes the primary type of driving impairment, many other conditions (e.g., visual impairment, dementia, and seizure disorders) can cause impaired driving. Orthopaedic injuries can likewise cause impaired driving. Lower-extremity injuries and surgical procedures slow brake-reaction times2. It generally takes 9 weeks after an ankle-fracture surgical procedure for brake-reaction times to return to normal3 and 6 weeks for brake-reaction times to normalize after the initiation of weight-bearing after major lower-extremity trauma4. Brake-reaction times are also substantially impaired with knee or ankle immobilization5. In this case scenario, the patient intended to resume driving against medical advice, despite the inherent dangers. This scenario raises several ethical concerns related to autonomy, confidentiality, and safety. The ethical …