Walking Boot Research Articles

Treatment of Avulsion Fractures of the Base of the Fifth Metatarsal with Walking Boot and Hard-Soled Shoes: A Comparative Study

Category:Midfoot/Forefoot, TraumaIntroduction/Purpose:Acute avulsion fractures of the base of the fifth metatarsal are common and usually treated non- surgically with satisfactory outcomes. Forms of conservative treatments are described such as elasticated bandaging, immobilization in a cast, walking boot and hard-soled-shoes.The aim of this study was to compare the clinical and functional outcomes, time to return to the previous activities, time and rate of fracture healing of the patients with avulsion fracture of the base of the fifth metatarsal treated in a hard-soled-shoes (HSS) or in a walking boot (WB). Our null hypothesis is that a less rigid immobilization without restriction of the ankle yields the same final results.Methods:A retrospective and comparative study of 72 patients with acute avulsion fractures of the base of the fifth metatarsal treated with the WB or the HSS, from March 2014 to November 2018. The average age of the patients was 41,25 (range, 11-88) and there were 56 female and 16, male. 39 were treated with the WB and 33, with the HSS. Patients with comorbities that could interfere in the rate and time of bony healing (diabetes and inflammatory joint disease), associated ankle ligament lesions and loss of follow-up were excluded.Patients were followed regularly until they were clinically asymptomatic and able to return to their previous activities (work, daily activities, sports). We retrospectively reviewed medical records containing the visual analogue scale (VAS) for pain and the american orthopaedic foot and ankle society (AOFAS) score of each visit as well as radiographic exams to evaluate time and rate of fracture healing.Results:Patients of both groups had similar VAS and AOFAS scores in 8 (p=0,34 and p=0,83) and 12 (p=0,25 and p=0,79) weeks. Age and gender distribution in the two groups were equal (p=0,23 and p=0,34, respectively). Time taken to return to the previous activities were not significant different between both groups, with the HSS group taking 8,33 weeks and the WB taking 9,73 weeks (p=0,10). The mean time for bone consolidation was significant higher in the HSS group, taking 8,64 weeks while in the WB took 7,18 weeks (p<0,001). Only 1 case of non-union was observed in the WB group and none in the HSS group.Conclusion:Our study concluded that avulsion fractures of the base of the fifth metatarsal can be treated equally with the HSS or the WB. Both types of immobilization showed to be equivalent in terms of clinical and function evaluation, return to the previous activities without difference in the rate of the fracture consolidation.

Isolated Fibular Stress Fractures: Demographic and Radiographic Factors

Category:Ankle, TraumaIntroduction/Purpose:Fibular stress fractures are rare injuries that are incompletely understood in terms of pathogenesis and predisposing factors. While stress fractures all involve relative stress concentration in a finite area leading to local mechanical failure, the risk factors for this injury have not been assessed. Their relative rarity has made understanding of these risk factors difficult. In a retrospective case series, we sought to define demographic and radiographic risk factors for isolated fibular stress fractures.Methods:We retrospectively reviewed the records of 13 patients with isolated fibular stress fractures at our institution between January 2010 and November 2018. We collected and analyzed baseline demographic data and radiographic parameters including prior history of fracture, location of stress fracture, bone quality, and heel alignment.Results:The cohort consisted of 6 men and 7 women with a mean age of 41.8 years at the time of diagnosis of the fibular stress fracture. The average BMI in the cohort was 28.5 kg/m2. The location of the stress fracture was in the distal third of the fibula in 69.2% (9/13), proximal third in 23.1% (3/13), and middle third in 7.7% (1/13). There was no evidence of osteopenia on radiographic analysis in any patients, by assessment of the senior author and attending radiologist at our institution. Isolated stress fractures in the distal third of the fibula were observed more commonly in women. Distal fibula stress fractures were associated with physiologic hindfoot valgus, while proximal fractures were seen with a varus hindfoot.Conclusion:In this retrospective case series of a rare injury, isolated stress fractures in the distal third of the fibula were the most common fibular stress fracture. Proximal fibular stress fractures were associated with a varus hindfoot. All fractures in this case series healed with immobilization in a walking boot with or without a short period of nonweightbearing.

Effect of a Controlled Ankle Motion Walking Boot on Syndesmotic Instability During Weightbearing: A Cadaveric Study.

Background:Syndesmotic injuries can lead to long-term complications; hence, they require careful management. Conservative treatment is adequate when 1 syndesmotic ligament is injured, but surgery is often necessary to achieve articular congruity when 3 syndesmotic ligaments are ruptured. However, there is some controversy over the best treatment for 2-ligament injuries.Purpose:To evaluate the effect of a controlled ankle motion (CAM) walking boot on syndesmotic instability following iatrogenic isolated anterior inferior tibiofibular ligament (AiTFL) injury and combined AiTFL/interosseous ligament (IOL) injuries in a cadaveric simulated weightbearing model.Study Design:Controlled laboratory study.Methods:Ten cadaveric specimens were dissected to expose the tibial plateau and syndesmosis. The specimens were fitted to a custom-made device, and a reproducible axial load of 750 N was applied. Iatrogenic rupture of the syndesmotic ligaments (AiTFL + IOL) was done sequentially. Uninjured syndesmoses, isolated AiTFL rupture, and combined AiTFL/IOL rupture were compared with and without axial loading (AL) and CAM boot. The distal tibiofibular relationship was evaluated using a previously validated computed tomography scan measurement system. Wilcoxon tests for paired samples and nonparametric data were used.Results:The only difference noted in the distal tibiofibular relationship during AL was an increase in the external rotation of the fibula when using the CAM boot. This was observed with AiTFL rupture (8.40° vs 11.17°; P = .009) and combined AiTFL/IOL rupture (8.81° vs 11.97°; P = .005).Conclusion:AL did not cause a significant displacement between the tibia and fibula, even when 2 ligaments were ruptured. However, the CAM boot produced a significant external rotation with 1 or 2 injured ligaments.Clinical Relevance:Further studies are needed to assess the capacity of the CAM walking boot to prevent malreduction when external rotation forces are applied to the ankle. Moreover, special care should be taken during the fitting of the CAM boot to avoid overinflation of the cushions.

Effects of a corrective heel lift with an orthopaedic walking boot on joint mechanics and symmetry during gait

BackgroundOrthopaedic walking boots are commonly prescribed following injury and surgery. The boot creates a leg length discrepancy which is thought to affect limb symmetry and gait mechanics. This study aimed to examine the effects of a corrective heel lift for the contralateral limb on the mechanics and symmetry of walking with an orthopaedic walking boot. Research question: Does a corrective heel lift reduce biomechanical alterations and asymmetries caused by an orthopaedic boot during gait? MethodsHealthy males (n=17) walked with normal shoes (Shod), an orthopaedic boot (Boot), and a corrective heel lift on the contralateral limb to the boot (Lift). A 10-camera motion capture system (Vicon, 100Hz) and four force platforms (AMTI, 1000 Hz) recorded lower extremity biomechanics. Pairwise statistics tested for differences in hip and knee kinematics and kinetics, and a symmetry index quantified limb symmetry. FindingsThe Boot affected the sagittal and frontal plane hip mechanics and transverse plane knee mechanics (p<0.05), and increased the asymmetry compared to the Shod condition. The Lift improved the symmetry of some measures but increased the frontal plane hip asymmetry compared to the Boot. However, introducing the Lift did not change all kinematic variables affected by the boot. SignificanceThe Lift reduced some of the asymmetries introduced by the Boot, but also introduced new asymmetry in the hip frontal plane motion. The leg length discrepancy caused by the boot is probably not the only cause of altered gait mechanics. Prescribing a heel lift to a patient with an orthopaedic walking boot should be based on the individual patient’s needs.

Characterization of compliance to weight-bearing protocols and patient weight-bearing behavior during the recovery period in lower extremity fractures: a pilot study

Background: To promote fracture healing and limit complications, clinicians typically instruct patients with lower extremity fracture to be nonweight or partial-weight bearing or to bear weight as tolerated during the recovery period. Although this practice represents the standard of care, continuous patient compliance to weight-bearing protocols and actual patient weight-bearing progression remain unknown. This study aimed to characterize patient compliance towards weight-bearing protocols and weight-bearing progression during recovery. Methods: Eleven patients with lower extremity fracture consented to participate in this observational study. Postoperatively, patients were instructed to follow weight-bearing protocols based upon the treating clinicians’ recommendation. Patients were fitted with an underfoot load monitor integrated into the sole of a walking boot. Continuous load data from each patient were used to quantify the number of days patients were compliant with the weight-bearing protocol. Results: Overall, patients were unable to comply to nonweight-bearing and partial-weight-bearing protocols. Patients performed nonweight bearing and partial weight bearing only 24% and 12% of the time, respectively. Patients were most compliant (72%) to the weight bearing as tolerated protocol. Additionally, weight-bearing progressions either consistently increased (46%), remained relatively constant (27%), or remained constant initially and then suddenly increased (27%). Conclusions: Continuous compliance data from this study indicate that patients do not comply with weight-bearing protocols. Additionally, the variety of weight-bearing progressions, with limited complications, may suggest that patients are able to self-regulate their weight bearing without compromising healing outcomes.

Heel Injury-Figure Skate

HISTORY: A nine year old female figure skater presented with 6 weeks of atraumatic right foot pain. She recently started training double jumps prior to the onset of pain. Pain was located on the plantar side of the right midfoot and she initially noticed it following practices. Weight bearing increased her pain and eventually it hurt during practice as well as after practice . No changes in training time or frequency. She has been figure skating for two years. No history of previous foot injuries or bone stress injuries. No family history of osteoporosis. Her past medical history is significant for chronic Lyme’s disease. PHYSICAL EXAM: Ht 4' 6" (1.372 m) | Wt 69 lb (31.3 kg) | BMI 16.64 kg/m2 (56 percentile), Healthy and NAD. Accompanied by her mother. Examination: Inspection: Neutral foot type. Normal alignment of lower extremities. There was no redness, swelling, or skin changes. Palpation: moderate tenderness on the right plantar mid foot. Range of motion: there was full active range of motion of the ankle, without significant pain. Strength: Muscle strength (ankle plantarflexion, dorsiflexion, inversion, eversion) full. Special tests: Fracture test (tap, percussion, bump) negative, squeeze test negative, anterior drawer test negative, Talar tilt test negative, Stress test negative, Thompson test negative. DIFFERENTIAL DIAGNOSIS: 1.Navicular bone stress injury 2.Tarsal coalition 3.Anterior tibialis tendinopathy 4.Posterior tibialis tendinopathy 5.Bone tumor 6.Nerve entrapment 7.Heel pad syndrome 8.Sever disease TEST AND RESULTS: 1.Ankle X-ray- No obvious fracture or callus 2.MRI Ankle- bone marrow edema in the neck of the calcaneus 3.DXA- Normal bone density FINAL DIAGNOSIS: Calcaneus bone stress injury TREATMENT AND OUTCOMES: 1.Decreased activity level 2.Non-weight bearing on crutches for 2 weeks 3.Walking boot for 3 weeks with partial weight bearing on crutches 4.PT 1-2x/ week for 2-3 weeks 5.Vitamin D 2000 IU everyday 6.Partial weight bearing to full weight bearing as tolerated 7.Gradual return to sports after 12 weeks of injury, when she did not have pain with ambulation, and repeat MRI showed no evidence of residual bone marrow edema.

Brake Response Time Recovery After Achilles Tendon Repair.

Background. This study evaluated when patients' brake response time (BRT) recovers after right Achilles repair. Methods. Institutional review board-approved prospective study of 60 patients. Assessments included visual analogue scale pain (VAS) score, Achilles Tendon Total Rupture Score (ATRS), and a driver readiness survey. Emergent brake pedal operation was simulated at 6 weeks postoperatively and repeated until patients achieved a passing BRT. Results. Fifty-seven patients completed the study. At 6 weeks, 54 of 59 (91.5%) patients had a passing BRT with a mean of 0.60 seconds (SD 0.08 seconds). Five (8.5%) patients had a failing BRT with a significantly higher mean of 0.95 seconds (SD 0.13 seconds, P = .01). At first testing, all patients were ambulating in a walking boot with removable heel wedges. Those who passed were using significantly fewer wedges (mean 1.9 vs 2.6 wedges, P = .04). Mean VAS pain scores (Passed: 1.1, SD 1.57, vs Failed: 2.8, SD 3.35, P = .32) were not significantly different. The mean ATRS was significantly lower among those who passed (63.7, SD 16.7, vs 85.4, SD 11.1, P = .01. Three patients repeated testing at a mean 7.3 weeks (range 6.7-8). All achieved passing times (mean 0.68 seconds, range 0.55 to 0.77 seconds). The driving readiness survey was 100% sensitive but 31.3% specific for passing BRT. Its positive predictive value was 80%, and its negative predictive value was 100%. Conclusion. BRT normalizes around 6 to 7 weeks after open right Achilles tendon repair. The ATRS and driver readiness questionnaire corresponded to achieving a passing BRT. Levels of Evidence: Prognostic Level II: Prospective Cohort Study.

Outcomes Following Treatment of the Infected Achilles Tendon.

Background:Infection following Achilles tendon surgery is a devastating complication and can be difficult to treat and often leads to poor outcomes. A number of treatments have been described, but there is little information concerning outcomes of these treatments. Our purpose was to evaluate the clinical and functional outcomes of patients who have undergone treatment for an infected Achilles tendon after acute and chronic midsubstance repair.Methods:We retrospectively reviewed the medical records of 20 patients who had undergone surgical treatment for an infected Achilles tendon between 2000 and 2016. The mean follow-up time was 21 months (range, 2-68 months). All patients underwent extensive debridement of the tendon with removal of all infected tissue and foreign material. Soft tissue wound coverage was utilized for large wounds that were not amenable to primary or secondary closure. All patients received culture-specific intravenous (IV) antibiotics for 3 to 6 weeks. Postoperatively, the extremity was immobilized in a splint followed by a cast until the wound was healed. The cast was then replaced with a walking boot and the patients were provided a physical therapy program. Functional outcomes were measured using the Foot and Ankle Ability Measure (FAAM) Activity of Daily Living (ADL) scale.Results:All wounds had healed at the time of last follow-up. Three patients (15%) required an unplanned return to the operating room for repeat debridement. All patients were able to walk without the use of a gait aid. Five patients (25%) required continued use of a boot or brace during ambulation. Fourteen patients participated in the FAAM ADL survey. There were 6 patients lost to follow-up. The average FAAM score was 87 (range, 71.4-100). At last follow-up, most patients reported their overall function as “normal” or “nearly normal.” Eradication of infection and satisfactory functional results can be attained after radical debridement, wound closure, and administration of culture-specific IV antibiotics.Level of Evidence:Level IV, retrospective case series.

Center of pressure in a walking boot shifts posteriorly in patients following lower leg fracture

BackgroundStudies have shown that the ambulatory behavior and amount of weight bearing performed by lower leg fracture patients, increases over time. It is likely that gait features, such as center of pressure (CoP), also change over time. Research QuestionThe purpose of this study was to characterize changes in CoP exhibited by lower leg fracture patients wearing a walking boot during the recovery period. MethodsApproximately 2 weeks post-surgery, seven lower leg fracture patients were fitted with a MaxTrax walking boot which was integrated with the Ambulatory Tibia Load Analysis System, an underfoot load monitoring system. Patients wore the walking boot for 2–12 weeks resulting in continuous load data during the recovery period. Ambulation was filtered from the raw data and daily average CoP values were calculated by averaging the CoP vectors from all steps in a given day. ResultIn general, the CoP vector varied in both the x and y directions during the initial stages of recovery but was more uniform during the later stages of healing. In 6/7 patients, the CoP in the y direction was closer to the forefoot during the initial stages of healing but shifted posteriorly as time post-surgery increased. The single patient that did not exhibit a posterior shift in CoP was also the only patient to develop a non-union. CoP in the x direction show a less clear trend. CoP in the x direction exhibited a medial shift in 5 patients and a lateral shift in 2 patients. SignificanceDuring lower leg fracture recovery in a walking boot, the CoP in the y direction shifts posteriorly as time post-surgery increases and CoP monitoring may become a useful tool to monitor individual patient healing progression.

SESAMOID INJURIES IN PEDIATRIC AND ADOLESCENT ATHLETES PRESENTING TO SPORTS MEDICINE CLINIC

Background Sesamoid injuries of the first metatarsal phalangeal joint in athletes occur with sports that place repetitive stress on the plantar aspect of the great toe. Performing artist athletes are particularly at risk for injury given the load placed on the hallucal sesamoid bone often inherent in the activity. Risk factors may include choice of sport, volume of training, sex, bone density, BMI and biomechanical profile of the lower extremity. Hallucal sesamoid evaluation and treatment remains poorly defined in the literature. The aim of this study is to analyze all sesamoid injuries presenting to a sports medicine clinic. The goal of the study is to increase understanding of the injury profile, diagnostic evaluation, treatment regime, and return to sport of athletes with hallucal sesamoid injuries. The long-term goal is to develop evaluation and treatment algorithms that serve to guide clinical decision-making, and improve time to return to sport. Methods A comprehensive retrospective chart review was conducted of athletes presenting to a tertiary level sports medicine clinic located within a pediatric medical center. Electronic medical records were searched using the search term sesamoid. To be included in the study, the injury had to definitively involve the hallucal sesamoid and be related to sports participation. Exclusion criteria included patients with a chronic disease or condition that might affect bone healing or confuse the diagnosis of sesamoid injury, prior history of surgery to the foot, and insufficient management records. Descriptive statistics were used to analyze outcome variables including specific diagnosis, clinical prognoses, diagnostic imaging tools and treatment types. Additionally, a correlation analysis was performed for time from pain onset to first clinic visit, and time to return to participation. Little or no correlation was considered 0.00-0.25, weak correlation was considered 0.25-0.50, moderate correlation was considered 0.50-0.75 and strong correlation was considered 0.75 -1.00. Results 326 athletes with 359 hallucal sesamoid injuries were identified. The mean age of the cohort was 15.8 ± 3.8 years (median: 15.3, 95% CIs: 15.46 – 16.24); 86% (n=309) were female and 14% (n=50) of the injuries were male. The mean BMI of the cohort was 21.28 ± 3.5 mg/kg2. Table 1 presents the sports for the athletes in the cohort. The leading sports included 40% (n=144) dance, 13% (n=48) running, and 13% (n=47) soccer. Activities that top the list for females include dance 44% (n=137) and running 13% (n=39). In comparison, male athletes participated in soccer (20%, n=10), running (18%, n=9), and football (10%, n=5) as well as other diverse sports. The most common injuries across both sexes were sesamoiditis (30%, n=107), followed by sesamoid stress fracture (13%, n=46). Table 2 Where self-reported data on dance/sport practice time was recorded, 31% (n=65) reported practicing 10-15 hours per week. Figure 1 The average reported time between injury or the onset of pain to the first clinic visit was 143 days (median: 42, 95% CIs:116.87-169.15). The mean time between pain onset and first clinic visit was greater for female athletes as compared to male athletes (146 days and 119 days). The average time from first presentation to clinic to returning to participation was 115 days (median: 72, CIs:100.7-129.49). Spearman’s rho demonstrated a strong correlation between time from pain onset to first clinic visit and the time to return to participation in both males (? (rho) = 0.82, p &lt; 0.001) and females (? = 0.79, p &lt; 0.001). Males experienced a shorter duration from the first clinic visit to return to participation (mean: 72 days, median 33), than females (mean: 121 days, median 77). The most common diagnostic imaging modalities used were radiographs (72.14%, n=259) and MRI (56.55%, n=203). In both males and females the most common initial treatments included a combination of: walking boot (51.53%, n= 185), physical therapy (38.72%, n=139), and activity modification (34.82%, n=125). These remained the most popularly prescribed treatments in the second and third treatments as well. Conclusions/significance Female athletes participating in dance and running, and male soccer, running and football athletes lead the list for injury to the hallucal sesamoid. Sesamoiditis and sesamoid stress fracture were the leading diagnoses in this cohort. Athletes who presented to clinical attention sooner also returned to sport/dance sooner when compared to athletes who delayed seeking medical attention. Continued research will serve to support anticipatory guidance and education surrounding hallucal sesamoid clinical presentation and need for timely evaluation and treatment in order to minimize time loss from sport/performing artist activity. [Table: see text][Table: see text][Figure: see text]

Open Reduction and Internal Fixation of Acute Lisfranc Fracture-Dislocation with Use of Dorsal Bridging Plates.

Lisfranc injuries consist of a wide spectrum of injuries, ranging from subtle injuries to severe fracture-dislocations. Injuries with instability of the tarsometatarsal, intercuneiform, or naviculocuneiform joints should be treated with anatomic reduction and stable fixation. The best method of fixation is debated. Transarticular screw fixation has the disadvantage of damaging the tarsometatarsal joints. Bridging the tarsometatarsal joints with use of low-profile locking plates avoids the placement of screws through the joint and potentially reduces the risk of posttraumatic arthritis. Primary arthrodesis of the 3 medial tarsometatarsal joints is also an option in treating Lisfranc injuries and has been shown to lead to better outcomes compared with transarticular screw fixation in ligamentous Lisfranc injuries. In this article, we show the technique of open reduction and internal fixation of Lisfranc fracture-dislocation with use of dorsal bridging locking plates. The following steps are presented in the video: (1) incision technique with use of a dorsomedial incision and a dorsolateral incision, (2) open reduction and temporary fixation of the tarsometatarsal joints with use of Kirschner wires, (3) confirmation of anatomic reduction of the tarsometatarsal joints with direct visualization and fluoroscopy, (4) fixation of the medial 3 tarsometatarsal joints with dorsal bridging locking plates, (5) placement of a "homerun" screw from the medial cuneiform to the base of the second metatarsal, (6) fixation of the fourth and fifth tarsometatarsal joints with Kirschner wires, and (7) checking of reduction and fixation with use of fluoroscopy and performance of wound closure. Postoperatively, the foot is kept non-weight-bearing in a below-the-knee cast for 6 weeks, followed by 6 weeks of protected weight-bearing in a walker boot. Any Kirschner wires fixating the fourth and fifth tarsometatarsal joints are removed 6 weeks postoperatively. We prefer to remove the dorsal bridging plates 4 to 6 months postoperatively. Anatomic reduction and stable fixation is associated with better functional outcomes. Hardware failure and loss of reduction are potential complications that can lead to worse outcomes.

Associated Joint Pain With Controlled Ankle Movement Walker Boot Wear.

Background:Controlled ankle movement (CAM) walker boots may cause gait alterations and leg-length discrepancy. This study evaluates secondary site pain relating to immobilization in a CAM walker boot.Methods:Patients wearing a CAM walker boot were prospectively enrolled and evaluated for new or worsened secondary site pain. Surveys at four time points were completed to evaluate secondary site pain severity and its effect on function.Results:The study included 46 patients (mean age, 49 years). At transition out of the boot (mean, 4.2 weeks), 31 patients (67%) reported pain which was new or worse than at baseline. The sites most susceptible to pain were lower back, contralateral hip, and ipsilateral knee. Most pains (84%) began within the first 2 weeks of boot wear. Secondary site pain was less common after transition out of the boot: 18 patients (39%) at 1 month and 15 patients (33%) at 3 months.Conclusion:Secondary site pain after CAM walker boot wear is common. The frequency and severity of pain lessened after transition out of the boot. Yet, one-third of patients still had new or worsened secondary site pain 3 months after cessation of boot wear.

Metatarsal fracture management

Metatarsal fractures represent a significant proportion of all foot injuries. Patients present with pain and difficulty with ambulation either after a traumatic insult or an increase in activity level. Diagnosis requires a foot X-ray series and tarsometatarsal injuries may need to be excluded with a CT. Management is determined by patient factors and fracture pattern. The aim of treatment is to preserve the longitudinal and transverse arches of the forefoot and restore the alignment of the metatarsals to achieve normal weight distribution. Open fractures, fractures with sagittal plane displacement more than 10° or with 3–4 mm displacement in any other plane may benefit from surgical intervention. The majority are minimally displaced and can be treated with a walking boot or hard-soled shoe with arch support or non-weight bearing in a short leg cast for 6–8 weeks. Any suggestion of instability or displacement for the first metatatarsal will require surgical treatment. Proximal fifth metatarsal fractures have differing treatments depending on the location of the fracture.

Immediate Weight-Bearing Protocol for the Determination of Ankle Stability in Patients With Isolated Distal Fibular Fractures.

To evaluate an alternative protocol for allowing immediate weight-bearing (WB) as tolerated in a functional walking boot in patients with a medial clear space (MCS) of less than 4 mm on nonstressed initial radiographs with subsequent WB radiographs at 1-week follow-up to determine if this can differentiate stable from unstable distal fibular fractures. Retrospective case series. Level 1 trauma center. Seventy-nine patients who sustained an isolated distal fibular fracture with an MCS less than 4 mm on initial non-weight-bearing radiographs during a 6-year period. Patients with MCS less than 4 mm on 1-week radiographs were treated nonoperatively. Patients with MCS greater than or equal to 4 mm were treated operatively. Medial clear space measurements on WB ankle radiographs at the time of radiographic bony union. Two of the 79 (2.5%) patients had an MCS greater than 4 mm at 1-week follow-up with WB radiographs and underwent operative fixation. The remaining 77 patients were treated nonoperatively. All 77 patients had an MCS less than 4 mm on WB radiographs at the time of radiographic healing. These results suggest that our immediate weight-bearing protocol may be an effective method for determination of functional ankle stability only in the setting of an isolated distal fibula fracture with MCS less than 4 mm. However, it should be cautioned that careful evaluation of WB radiographs for joint asymmetry and/or MCS widening is mandatory to avoid poor outcomes. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic All-Inside Anterior Talofibular Ligament Repair Through a Three-Portal and No-Ankle-Distraction Technique.

Ankle instability is a common consequence of ankle sprains. Injury of the anterior talofibular ligament (ATFL) is the most common cause of ankle instability1. Arthroscopic treatment of ankle instability is an emerging field attracting increased interest among surgeons2-10. The arthroscopic all-inside ATFL repair allows the surgeon to explore the ankle joint, treat concomitant pathology when encountered, and reattach the injured ATFL to its fibular anatomical location. The aim of this article is to describe the arthroscopic all-inside ATFL repair through a 3-portal no-ankle-distraction technique. After patient positioning, anteromedial and anterolateral portals are created. An accessory anterolateral portal is created just anterior to the fibula and about 1 cm proximal to the tip of the lateral malleolus. The arthroscope is introduced through the anteromedial portal, and the instruments are introduced through the anterolateral portal. Recognition of the ligament and evaluation of the ligament tear with a probe are required. The footprint for the fibular attachment of the ATFL is debrided. The ligament is penetrated with a suture passer. A nitinol loop is pushed and then is pulled out through the accessory portal. The nitinol wire is replaced by a double high-resistance suture. The limbs of the suture located in the accessory portal are passed through the anterolateral portal. Next, one or both limbs of the suture are passed through the loop suture. Pulling of the suture limbs introduces the loop into the joint and the ligament is grasped by the suture. The tunnel for the anchor is drilled. The knotless anchor is loaded with the suture, and the anchor and suture are introduced with the ankle in dorsiflexion and valgus. Postoperatively, the ankle is immobilized with a removable walking boot for 4 weeks. Once use of the walking boot is discontinued, physical therapy is started. Nonoperative treatment with physiotherapy or sports restriction can be an alternative for patients with surgical contraindications or as a first step of treatment. Open techniques (repair or reconstruction) or other arthroscopic-assisted techniques (arthroscopic introduction of anchors and percutaneous passage of sutures, or arthroscopic-assisted reconstruction) are possible surgical alternatives to the described technique to treat ankle instability. The described technique has the advantage of being done with a minimally invasive approach and providing an anatomical repair of the ligament. Concomitant intra-articular pathology can be addressed during the procedure through the same arthroscopic approaches. Early rehabilitation and the lack of intra-articular knots are additional benefits of the technique.

Acute spontaneous bilateral rupture of the Achilles tendon

This is a case report of a 67-year-old active, healthy, male patient who played sports. He presented with pain and bilateral ecchymosis in the calf area. Data from the patient’s history, a physical examination and complementary exams confirmed a diagnosis of atraumatic spontaneous bilateral Achilles tendon rupture. Surgical treatment was performed using the percutaneous technique (the Achillon device) bilaterally. In thepostoperative period, the patient used a walking boot with a 3-cm heel lift in maximum equinus for 45 days and in a neutral position until 60 days after the procedure. The patient began rehabilitation with physical therapy and returned to his sporting activities without restrictions. Level of Evidence V; Prognostic Studies; Expert Opinion.

Boots Are Not Made for Driving: A Cautionary Case Report About the Dangers of Driving in a CAM Walker Boot and Literature Review

This case report is the first documented case of a serious motor vehicle accident caused by a patient driving in a controlled ankle motion (CAM) walker boot. The real-life nature and severity of injury in this case supplements the existing experimental studies on the dangers of driving while immobilized in a CAM boot and is likely to resonate strongly with both patients and surgeons. With CAM boots used so commonly after lower limb surgery, this case not only has the potential to change practice as an educational tool for patients but also raises important medicolegal implications for orthopaedic surgeons. Levels of Evidence: Level V

Results of Nonoperative Treatment for Symptomatic Tarsal Coalitions.

Introduction: Recommendations for the initial treatment (nonoperative measures to surgical excision) of symptomatic tarsal coalitions vary. Because nonoperative outcomes are poorly established, we retrospectively evaluated their success in preventing surgery and achieving pain relief for pediatric patients with symptomatic tarsal coalitions.Materials and methods: A retrospective study of pediatric patients with symptomatic tarsal coalitions treated at a single institution was undertaken. Clinical notes were examined for treatment methods, response to treatment, and need for additional procedures. A statistical analysis was performed using the chi-square and Mann-Whitney U tests.Results: Fifty symptomatic tarsal coalitions (mean patient age, 11.4 years; range, 8.1–17.9) were treated with nonoperative measures. Surgery was not required in 79% of calcaneonavicular and 62% of talocalcaneal coalitions. Pain relief was achieved in 53% of 81 nonoperative treatment trials. Continuous immobilization via casting, intermittent immobilization via walking boot, and supportive measures were not significantly different in pain relief (p = 0.35) or preventing surgery (p = 0.62).Conclusion: Nonoperative treatment methods have the potential to achieve pain relief and prevent or delay surgery for symptomatic tarsal coalitions. However, some families may elect to forgo nonoperative measures knowing that surgery may eventually be required.

Associated Joint Pain with Controlled Ankle Movement (CAM) Walker Boot Wear

Category: Ankle Introduction/Purpose: A controlled ankle movement (CAM) walker boot is often prescribed for patients with a lower extremity injury or disorder. CAM boot wear, however, may cause gait alterations and leg-length discrepancy, which are commonly associated with joint pain. This study evaluates the location, frequency and duration of secondary site pain relating to immobilization in a CAM walker boot. Methods: Patients wearing a CAM walker boot for treatment of a foot or ankle injury were prospectively enrolled and evaluated for new or worsened secondary site pain. Surveys at four time points were completed to evaluate the presence of secondary site pain, its severity, and its impact on overall function. Results: The final study population included 46 patients (mean age 49 years). At transition out of the boot (mean, 4.2 weeks), 31 patients (67%) reported secondary site pain either new or worse than baseline with an average of 1.6 secondary pain sites. The secondary sites most susceptible to pain were the lower back, contralateral hip, and ipsilateral knee. A majority (84%) of these pains began within the first two weeks of boot wear. Secondary site pain was less common after transition out of the boot: 18 patients (39%) at 1 month, 15 patients (33%) at 3 months. The mean VAS for secondary site pains at transition out of boot was 51.2. Statistical significance was found correlating secondary site pain and a history of chronic pain (P=.04). Conclusion: Secondary site pain after CAM walker boot wear was common. The frequency and severity of pain lessened with time after transition out of the boot. Yet, one-third of patients still had new or worsened secondary site pain three months after cessation of boot wear.

Outcomes following treatment of the infected Achilles tendon

Category: Sports Introduction/Purpose: Infection following Achilles tendon surgery is a devastating complication and can be difficult to treat. Our purpose was to evaluate clinical and functional outcomes of patients who have undergone treatment for an infected Achilles tendon. Methods: We retrospectively reviewed the medical records of 20 patients who had undergone surgical treatment for an infected Achilles tendon between 2000 and 2016. The mean follow-up time was 21 months (range 2-68 months). All patients underwent extensive debridement of the tendon with removal of all infected tissue and foreign material. Soft tissue wound coverage was utilized for large wounds that were not amenable to primary or secondary closure. All patients received culture specific intravenous antibiotics for three to six weeks. Postoperatively, the extremity was immobilized in a splint followed by a cast until the wound was healed. The cast was then replaced with a walking boot and the patients were provided a physical therapy program. Functional outcomes were measured using the Foot and Ankle Ability Measure (FAAM) Activity of Daily Living (ADL) scale. Results: All wounds had healed at the time of last follow-up. Three patients (15%) required an unplanned return to the operating room for repeat debridement. All patients were able to walk without the use of a gait aid. Five patients (25%) required continued use of a boot or brace during ambulation. The average FAAM score was 87 (range, 71.4-100). At last follow-up, most patients reported their overall function as “normal” or “nearly normal”. Conclusion: Eradication of infection and satisfactory functional results can be attained after radical debridement, wound closure, and administration of culture specific IV antibiotics.