Walking Cast Research Articles

Augmented repair of acute tendo Achilles ruptures with gastrosoleus turn down fap

Background:We present the results of primary repair of acute tendo Achilles (TA) rupture augmented with gastrosoleus turn down flap technique.Patients and Methods:78 consecutive patients with a complete acute rupture of the Achilles tendon operated between 1993 and 2004 were included in study. We performed a modification of the Lindholm technique in which the primary Kessler suture repair of the tendon was augmented by a turn-down ~3 cm × 10 cm gastrosoleus aponeurosis flap. In all cases, a short-leg circular walking cast was applied at 90° of the ankle dorsiflexion for 3 weeks and all the patients were encouraged to full weightbearing ambulation immediately. After removal of the cast, isometric and isokinetic ankle exercises were performed for 3 weeks. Modified Rupp Score was used to evaluate the subjective satisfaction.Results:All of patients returned to daily activity and 54 (69%) of them returned to previous sport activity. The tendon repair failed in two patients and they were reoperated with an allograft. Three patients developed infection and one of them required débridement. One developed deep venous thrombosis and two permanent sural nerve injuries were encountered. One of the patients had a severe skin necrosis, which was treated with rotation flap. The mean Rupp score was 29 (3–33).Conclusion:Primary repair of acute tendo Achilles rupture augment with gastrosoleus turn down flip technique in combination of immediate weightbearing ambulation provides a good outcome, but is associated with similar complication rates to the previous literature.

Effects of Orthopaedic Immobilization of the Right Lower Limb on Driving Performance

The effects of immobilization of the right lower limb on driving performance are unknown. Therefore, clinicians and legislators cannot put forth recommendations for road safety for patients requiring such immobilization. The objective of the present study was to evaluate the effect of two orthopaedic immobilization devices on the braking performances of healthy volunteers under simulated driving conditions. The braking performances of forty-eight healthy volunteers were evaluated under three conditions: wearing a running shoe, wearing a walking cast, and wearing an Aircast Walker on the right lower limb. A computerized driving simulator was used to measure the maximum force applied on the brake pedal during braking as well as the braking reaction time and the total braking time during emergency braking with and without a distractor. The mean braking forces applied with the shoe, the walking cast, and the Aircast Walker were 293.8, 275.4, and 287.2 lb (133.3, 124.9, and 130.3 kg), respectively. The value with the walking cast was significantly lower than that with the shoe or Aircast Walker (p < 0.0001); there was no difference between the shoe and the Aircast Walker. The adjusted mean braking reaction times during emergency braking without a distractor were 0.580 second (shoe), 0.609 second (cast), and 0.619 second (Aircast Walker). The value with the running shoe was significantly lower than that with either type of immobilization (p < or = 0.0001). With a distractor, the mean braking reaction time was shorter with the running shoe than it was with either form of immobilization (p < or = 0.0001); the mean time was also shorter with the walking cast than it was with the Aircast Walker (p = 0.003). During both emergency braking tasks (with and without a distractor), the mean total braking time was shorter with the shoe than it was with either type of immobilization (p < 0.0001). With a distractor, the adjusted mean total braking time was shorter with the walking cast than it was with the Aircast Walker (p = 0.035). Immobilization of the right lower limb affects the braking force as well as the braking reaction time and total braking time during emergency braking by healthy volunteers. While these changes are significant, their impact on the ability to drive safely during emergency braking situations is questionable. Future research into the impact of such immobilization on the emergency braking performances of patients is warranted to confirm these observations.

Early Ambulatory Treatment of Ankle Fractures Utilizing Surgical Fixation and Semi-Rigid Short Leg Walking Cast

Postoperative management of ankle fractures in athletic patients presents a unique challenge for the foot and ankle surgeon. Since the 1850’s, bandages impregnated with Plaster of Paris have been used to stabilize and support fractured bones. It has been widely recognized that early weight bearing and mobilization after ankle fracture surgery vastly decreases rehabilitation time and decreases the time of return to activity. This article describes the case of a patient who presented with a pronation-external rotation type 3 ankle fracture, which occurred while playing basketball. The patient was an elite high school athlete aspiring to play college basketball and was treated with open reduction and internal fixation consisting of two 1.5mm Kirschner wires medially and a syndesmotic screw laterally. The patient began ambulating with the use of a short leg walking cast 12 days postoperatively and was able to return to full activity at 7 weeks postoperatively, 1 week after removal of the syndesmotic screw.

KID syndrome patient with toe walking: A case report

Objective: To report on a 10-year-old boy with KID syndrome who presented with a new onset unilateral toe walking.Method: This patient's equinus contracture was evaluated clinically. The patient underwent to surgical lengthening of Achilles tendon. After the surgery, the patient was placed in a short-leg walking cast for 6 weeks and then received a rehabilitation programme involving stretching exercises.Results: Successful heel-to-toe gait was achieved in 3 weeks following surgery and rehabilitation.Conclusion: Surgical intervention and postsurgical rehabilitation may be indicated for children who present with toe walking attributed to contracture in the Achilles tendon.

Les ruptures du tendon du muscle tibial antérieur

In sports medicine, tears of the tibialis anterior are exceptional. We describe our experience with one case. Two types of injury can be observed: true tears involving the main body of the muscle under the pulley or the more distal portion at the insertion and fissurations. These injuries usually occur in a context of longstanding tenosynovitis or tendinopathy and are generally observed in runners. The mechanism requires stretching with the foot in forced plantar flexion and external rotation (fall backward with forefoot blocked). The diagnosis is clinical. Complementary explorations, excepting plain X-rays to search for a distal detachment from the bone, are not indispensable. In sports medicine, surgical treatment is required for full thickness tears. A plasty is usually performed with the third toe extensor. Recovery is long and progressive. In our experience, corticosteroid injections do not provoke these tears but can be useful for more rapid recovery in the athlete. After an injection, we immobilize the ankle for three weeks in a walking cast in order to “limit” the motivated athlete.

Incidence of Occult Fracture in Children With Acute Ankle Injuries

In skeletally immature children, it can often be difficult to differentiate occult Salter-Harris I fibula fractures from ankle sprains based on physical examination, and often, initial radiographs in both conditions are only notable for soft tissue swelling. The likelihood of a child having subsequent plain radiographic evidence of a fracture in this setting and the likelihood of subsequent fracture displacement have not been previously reported. The purpose of our study was to determine the incidence of occult fracture in these patients and the risk of fracture displacement. We performed a retrospective review of all children seen for acute ankle injuries over a 14-month period at a large tertiary care children's hospital. To be included in the study, patients needed to have acute ankle trauma, an open distal fibula physis, normal radiographs, and localized distal fibular tenderness on examination. Thirty-seven consecutive children met the inclusion criteria, with 1 child having 2 isolated injuries, one of each ankle, 4 months apart. All patients were initially placed in a short leg walking cast and allowed to weight bear as tolerated. Anteroposterior, mortise, and lateral radiographs of the ankle taken 3 weeks after injury were evaluated for periosteal new bone formation and/or fracture displacement. By 3 weeks after injury, there was periosteal new bone formation about the distal fibula in 7 (18%) of 38 ankles. No fractures were displaced during treatment, and no radiographs had greater than 1 mm of new bone formation visible. This is the first investigation reporting the frequency of plain radiographic evidence of occult distal fibula fractures in children. This study finds that 7 (18%) of 38 acute ankle injuries in children presenting with distal fibula tenderness and normal radiographs show evidence of periosteal new bone formation on follow-up radiographs, implying the presence of an occult fracture. There was no evidence of fracture displacement during treatment, and no fracture demonstrated greater than 1 mm of periosteal new bone.

Endoscopic bone grafting for management of nonunion of the tuberosity avulsion fracture of the fifth metatarsal

The most common fracture of the proximal fifth metatarsal is the tuberosity avulsion fracture. Most of the time, the fracture is relatively undisplaced and it can be treated conservatively with a hard-soled shoe or walking cast. For painful intra-articular nonunion, internal fixation with or without bone graft is the treatment of choice. We describe an endoscopic approach to treat nonunions of the tuberosity avulsion fracture. Under endoscopic guidance, the nonunion site can be debrided thoroughly and bone grafted without the need of extensive soft tissue dissection. Moreover, the condition of the fifth metatarsal cuboid articulation can be assessed and intra-articular pathology can be dealed with arthroscopically. Finally, the desired position of the screw can be guided by the arthroscopic aiming device.

Charcot neuro-osteoarthropathy—current standards

It is extremely important to have a high index of suspicion for Charcot neuro-osteoarthropathy (CN) and to encourage early presentation of the patient. This should be followed by a rapid diagnosis and early intervention, and with such a modern approach many CN can now be healed and deformity prevented. CN can be divided into two phases: acute active phase and chronic stable phase. The acute active phase includes those patients presenting early with normal X-ray and those presenting later with deformity and radiological changes of CN. The acute phase is characterized by unilateral erythema and oedema. The foot is at least 2 degrees C hotter than the contralateral foot. Patients should have initially an X-ray examination which, at this time, may be normal. We then proceed to two investigations: initially a technetium diphosphonate bone scan, which will detect early evidence of bone damage and also locate the site of this damage. If the result of the bone scan is positive, we would proceed to magnetic resonance imaging (MRI) examination, which would describe in more detail the nature of the bony damage. The aim of treatment is immobilization in a plaster cast until there is no longer evidence on X-ray of continuing bone destruction, and the foot temperature is within 2 degrees C of the contralateral foot. An alternative treatment is a prefabricated walking cast, such as the Aircast. A randomized controlled study of a single 90 mg pamidronate infusion has shown a significant reduction of the markers of bone turnover and skin temperature in treated, compared with control subjects although the fall in skin temperature was similar in both groups. There was a similar finding in a recent study with alendronate. Calcitonin has also been used in the acute stage and there was a more rapid transition to the stable chronic phase in the treated group compared with controls. In the chronic stable phase, the foot is no longer warm and red. There may still be oedema but the difference in skin temperature between the feet is usually less than 2 degrees C. The X-ray shows fracture healing, sclerosis and bone remodelling. The patient must now be rehabilitated and gradually moved from cast treatment to suitable footwear. The patient needs close observation to detect any relapse, which will be evident from further swelling and heat in the foot. Careful rehabilitation is always necessary after a long period in a cast.

A Modified Operation for Achilles Tendon Ruptures

Background Treatment of Achilles tendon rupture has long been at the center of debate. Hypothesis A new technique in surgical Achilles tendon repair allows for more stability and earlier rehabilitation. Study Design Case series; Level of evidence, 4. Methods One hundred Achilles tendon rupture patients (70 men, 30 women; age range, 16-54 years; mean age, 32 years) were treated by a newly modified method of repair. Twenty-one of these patients were high-level athletes, and 79 were recreational-level athletes. The average length of follow-up was 2.4 years (range, 1-6.3 years), and none of the ruptures included avulsion fractures. After adjusting the tendon to an adequate length using a Tsuge suture, each fibrous bundle was gathered in a longitudinal direction and fixed with a Bunnell-type suture. The same postoperative physical therapy protocol was applied to all patients: at 1 week, early full weightbearing with a walking cast was initiated, and at 2 weeks, patients began range of motion (ROM) exercises and were instructed to wear a hinged ankle-foot orthosis that permitted full plantar flexion but limited full dorsiflexion. From 6 weeks, patients started practicing double-legged heel raises. Results At an average of 10 weeks, ankle ROM was comparable to that of the nonoperated leg, and double-legged heel raises were achieved at an average of 7.6 weeks. On average, patients were able to do 20 continuous single-legged heel-raising motions (equivalent to manual muscle testing grade 5) at 15.4 weeks, and jogging started at 12.3 weeks. High-level athletes returned to their original sports level at an average of 5 months. Two reruptures (2%) were experienced, but no other complications occurred. Conclusion This surgical technique allows for strong repair stability and subsequent early weightbearing and ROM exercises.

Fractures of the Fifth Metatarsal in Children and Adolescents

Fractures of the fifth metatarsal are the most common metatarsal fractures in children. Their treatment is based on the adult literature. The purpose of our study was to identify the different types of fifth metatarsal fractures, to determine the mean time to healing, and to examine whether current adult recommendations can be extrapolated to children and adolescents. A total of 103 patients met the inclusion criteria. The fractures were classified according to location. Type I represented an apophyseal injury. Type II represented tubercle fractures with intra-articular extension. Type III injuries represented Jones fracture. Metatarsal neck and shaft fractures were included separately. Apophyseal fractures did well with a short-leg walking cast for 3 to 6 weeks. Displaced intraarticular fractures had a significant delay in healing versus nondisplaced ones. Jones fractures had delays in healing if not treated surgically. Neck and shaft fractures did well with casting. Most fractures of the fifth metatarsal in the pediatric population do well clinically after a course of walking cast, unless the fracture is an intra-articular displaced fracture type or the fracture occurs in the proximal diaphyseal area. Fixation of Jones fractures in active adolescents should be considered to allow faster return to regular activities and prevent refracture. We recommend non-weight bearing casts for all angulated or displaced intra-articular injuries to avoid delays in healing and angulation. From our series, it is evident that most pediatric fifth metatarsal fractures behave as those found in adults and can be treated similarly.

A Randomized, Controlled Trial of a Removable Brace Versus Casting in Children With Low-Risk Ankle Fractures

Isolated distal fibular ankle fractures in children are very common and at very low risk for future complications. Nevertheless, standard therapy for these fractures still consists of casting, a practice that carries risks, inconveniences, and use of subspecialty health care resources. Therefore, the main objective of this study was to determine whether children who have these low-risk ankle fractures that are treated with a removable ankle brace have at least as effective a recovery of physical function as those that are treated with a cast. This was a noninferiority, randomized, single-blind trial in which children who were 5 to 18 years of age and treated in a pediatric emergency department for low-risk ankle fractures were randomly assigned to a removable ankle brace or a below-knee walking cast. The primary outcome at 4 weeks was physical function, measured by using the modified Activities Scale for Kids. Additional outcomes included patient preferences and costs. The mean activity score at 4 weeks was 91.3% in the brace group (n = 54), and this was significantly higher than the mean of 85.3% in the cast group (n = 50). Significantly more children who were treated with a brace had returned to baseline activities by 4 weeks compared with those who were casted (80.8% vs 59.5%). Fifty-four percent of the casted children would have preferred the brace, but only 5.7% of children who received the brace would have preferred the cast. The cost-effectiveness acceptability curve was always >80%; therefore, the brace was cost-effective compared with the cast. The removable ankle brace is more effective than the cast with respect to recovery of physical function, is associated with a faster return to baseline activities, is superior with respect to patient preferences, and is also cost-effective.

Treatment of Freiberg Disease with Intra-articular Dorsal Wedge Osteotomy and Absorbable Pin Fixation

The purpose of this study was to evaluate the outcome of intra-articular dorsal wedge osteotomy and absorbable pin fixation for the treatment of Freiberg disease. From January of 1997, to July of 2003, 12 patients with symptomatic Freiberg disease had intra-articular dorsal wedge osteotomy through the affected metatarsal head fixed with absorbable polyglycolide pins. All 12 patients were women with an average age of 36 (range 16 to 59) years. The Smillie stage of necrosis ranged from II to V. Active range-of-motion exercise was allowed after 4 weeks of short-leg walking cast wear, and weightbearing on the forefoot was allowed after radiographic union was achieved. The mean followup was 45 (range 22 to 84) months. Radiographically, solid healing of all osteotomies was observed at an average of 10 (range 8 to 16) weeks. There was no evidence of displacement, osteolysis, sinus formation, or progression of osteonecrosis at final followup. Pain measurement on a visual analog scale had improved significantly from an average of 8.0 to 2.3 (p<0.05). The range of motion of the metatarsophalangeal joint increased by a mean of 26 (range 5 to 60) degrees. All patients were satisfied with the results and would have the surgery again. In patients with Freiberg disease, intra-articular dorsal wedge osteotomy restores congruity of the metatarsophalangeal joint, and fixation with absorbable pins provides adequate fixation and avoids a second procedure for implant removal.

A Prospective, Randomized Clinical Investigation of the Treatment of First-Time Ankle Sprains

Background Acute ankle ligament sprains are treated with the use of controlled mobilization with protection provided by external support (eg, functional treatment); however, there is little information regarding the best type of external support to use. Hypothesis There is no difference between elastic wrapping, bracing, bracing combined with elastic wrapping, and casting for treatment of acute, first-time ankle ligament sprains in terms of the time a patient requires to return to normal function. Study Design Randomized controlled clinical trial; Level of evidence, 1. Methods Patients suffering their first ligament injury were stratified by the severity of the sprain (grades I, II, or III) and then randomized to undergo functional treatment with different types of external supports. The patients completed daily logs until they returned to normal function and were followed up at 6 months. Results Treatment of grade I sprains with the Air-Stirrup brace combined with an elastic wrap returned subjects to normal walking and stair climbing in half the time required for those treated with the Air-Stirrup brace alone and in half the time required for those treated with an elastic wrap alone. Treatment of grade II sprains with the Air-Stirrup brace combined with the elastic wrap allowed patients to return to normal walking and stair climbing in the shortest time interval. Treatment of grade III sprains with the Air-Stirrup brace or a walking cast for 10 days followed by bracing returned subjects to normal walking and stair climbing in the same time intervals. The 6-month follow-up of each sprain severity group revealed no difference between the treatments for frequency of reinjury, ankle motion, and function. Conclusion Treatment of first-time grade I and II ankle ligament sprains with the Air-Stirrup brace combined with an elastic wrap provides earlier return to preinjury function compared to use of the Air-Stirrup brace alone, an elastic wrap alone, or a walking cast for 10 days.

Surgical treatment and results in 17 cases of open lacerations of the extensor hallucis longus tendon

There is a scarcity of information on extensor hallucis longus tendon injuries and published studies frequently offer conflicting treatment recommendations and results. This paper reports on the treatment and results of open lacerations of the extensor hallucis longus tendon in 17 patients treated by a plastic surgeon over a period of 12 years. All injuries occurred due to industrial accidents. All patients were males with a mean age of 30 years (range=21-49 years). All zones of tendon injury were represented except zones 2 and 5. Sixteen patients underwent surgical exploration within 24h of injury and one patient had a delayed repair using a tendon graft. The laceration of the tendon was complete in 15 patients, and in these patients, the tendon repair was protected for 6 weeks using k-wires to the big toe and short-leg walking cast. The remaining two patients had partial tendon lacerations and were treated conservatively (without tendon suturing) and immediate unrestricted mobilisation. One patient had significant soft tissue loss requiring reverse sural artery flap cover. At final follow-up (mean=3 months), the results of tendon repair were assessed as per the grading system of Lipscomb and Kelly, and the AOFAS hallux score for pain (maximum score of 40 points indicating no pain) and for functional capability (maximum score of 45 points). All patients healed with no infections or painful neuromas. Two patients experienced prolonged mild aching pain in the foot on walking, but the pain eventually resolved in both patients. All patients returned back to work 2.5-5 months after surgery. As per Lipscomb and Kelly's grading system, the result was graded as good in four patients and fair in the remaining 13 patients. No poor results were seen. The AOFAS hallux pain score was 40 points in all patients and the mean functional capability score was 42.1 points (range=40-45 points). A large series of extensor hallucis longus tendon lacerations is reported. Treatment and the methods of immobilisation are given for various zone and injury types. Although it is difficult to obtain a completely normal range of motion of the big toe after surgery, all patients are expected to recover good active extension and return back to work pain-free.

Correction of Neglected Clubfoot Using the Ilizarov External Fixator

This study was conducted to evaluate the corrective capability of the Ilizarov external fixator in the treatment of neglected clubfoot. Thirty patients (38 feet) with a mean age of 19 (5 to 39) years with severe deformities and stiff feet associated with neglected clubfoot were studied. A limited soft-tissue dissection, Achilles tenotomy, and plantar fasciotomy were done. Progressive correction of the deformities was achieved through a standard setting of the Ilizarov external fixator. The device was used for 16 weeks, on average, and after removal a short-leg walking cast was used for an additional 6 weeks, followed by an ankle-foot orthosis (AFO) for 6 months. The final outcome was scored as good (complete correction and no pain); fair (partial correction with plantigrade foot and occasional pain); or poor (nonplantigrade foot and continuous pain during walking). After a mean followup of 58 (range 12 to 107) months, the results were good in 30 feet (78.9%); fair in three feet (7.9%); and poor in five feet (13.2%). Early complications were a distal tibial fracture in one foot, dislocation of the first metatarsophalangeal joint in one foot, and arterial damage that resulted in amputation of the toes in one foot. Recurrence of the deformity was found in 19 feet (50%): 11 minor, three mild, and five severe. Spontaneous ankylosis developed in 28 feet (73.7%). Nine feet (23.7%) required arthrodesis for symptomatic arthritis of the ankle or midfoot and deformity that could not be treated with orthoses. The Ilizarov external fixator allows simultaneous correction of all the severe foot deformities associated with neglected clubfoot with minimal surgery, reducing risks of cutaneous or neurovascular complications and avoiding excessive shortening of the foot. Even in those patients in whom final corrective arthrodesis is necessary, this may be carried out with minimal bone resection, since the severe deformities of the foot and ankle have been corrected.

Slipper cast management of emergency foot problems

Foot conditions are frequently seen in the emergency department. In many cases, although weight bearing is painful, it is not precluded, per se. When a soft dressing does not provide sufficient support, a below knee walking cast may be applied. We present an alternative dressing that may be of benefit in selected foot injuries. The dressing is fashioned with cast padding, foam sheeting and plaster. It is designed and molded to fit like a slipper. The plaster slipper has distinct advantages in that it is comfortable, lighter for the patient, and avoids the problem of ankle stiffness. We believe that this option is underused in the emergency setting.

Bioelastic membranes for topical application of a thromboxane synthetase inhibitor for protection of skin from pressure injury: a preliminary study.

A previous study showed that topical exposure to bioelastic-thromboxane synthetase inhibitor-matrix resulted in local tissue concentrations of thromboxane synthetase inhibitor sufficient for thromboxane synthetase inhibition. The objective of this research was to use an animal model to determine if a dressing having controlled release of thromboxane synthetase inhibitor (dazmegrel) could be used to prevent tissue breakdown over pressure points, i.e., lesion at the assistive device-skin interface. The animal model studies utilized the greyhound, a dog that has thin skin, angular conformation, limited body fat and is predisposed to pressure ulcers similar to those occurring in humans. The model uses a short-limb walking cast on one pelvic limb with the severity of the dermal pressure lesions induced over the medial malleolus controlled by the amount of padding in the cast and length of time the cast is in place. The bioelastic matrix loaded with dazmegrel provided protection from shearing and pressure skin injury over the medial malleolus, as evidenced by a decrease in epidermal abrasion/ulceration as measured with planimetry. Histopathologic evaluation of the skin over the medial malleolus indicated a protective function of the bioelastic matrix as measured as lower numbers of neutrophils, lymphocytes, and decreased collagen density compared to such numbers when no bioelastic matrix was present. These studies provided evidence that bioelastic-thromboxane sythetase inhibitor- matrix helps in preventing or reducing the severity of pressure lesions, e.g., assistive device-skin interface wounds.

A neglected plantar dislocation of first metatarsophalangeal joint: a case report

We describe a 17-year-old male patient with bilateral postaxial polydactily and traumatic plantar dislocation of the right first metatarsophalangeal joint which was untreated for three months. He had discomfort on the lateral side of both forefoots and a painful deformation on the right great toe. The patient was treated with amputation of both supernumerary toes and open reduction of the first metatarsophalangeal joint by means of medial and dorsal first web space insicions and intramedullary K-wire fixation. A short leg walking cast was applied to the right limb. After six weeks, the cast and the K-wire were removed and physiotherapy of the joint was started. Twenty months after surgery no instability but mild osteoarthritic changes were encountered at the joint.

FOOT CRAMPING PAIN ??? RUNNER

HISTORY An 18-year-old male runner was referred to our sports medicine clinic with a 1-year history of cramping left foot pain. His symptoms developed insidiously when he increased his speed work training about 1 year previous, with an onset of severe left foot pain and tightness that would develop after about 20 minutes of exercise. The patient also noted occasional cramps in his calves after excessive exercise. He did not notice any swelling, numbness, tingling or burning sensations. He saw numerous private physicians and tried physical therapy, interdigital nerve block, and was immobilized in a walking cast for more than 1 month for a presumed stress fracture without effect. A family history revealed that a 29-year-old sister and uncle had symptoms of cramping in the hands with hard exercise or cold weather. PHYSICAL EXAMINATION The patient had no atrophy or fasciculations of his extremities or tongue. Neurovascular status was intact. He had no current pain associated with the foot with palpation, range of motion, or ambulation. He had full range of motion in all extremities as well as in the cervical and thoracolumbar spine. Neurologic examination, including detailed testing of mental status, cranial nerves, motor/sensory systems, muscle stretch reflexes, coordination, and gait were within normal limits, with the exception of mild proximal muscle weakness noted at the deltoids and triceps rated at 4/5 bilaterally. Distal upper and lower extremity strength were normal. DIFFERENTIAL DIAGNOSIS Compartment syndrome. Metatarsal stress fracture. Plantar fascitis. Interdigital neuroma. Myotonic syndrome. TEST AND RESULTS Blood studies, including cell count, electrolyte, chemistry panel: – Normal MRI scans of the foot: – No sign of interdigital neuroma, metatarsal stress fracture, tenosynovitis, and no evidence of tumor or mass. Stryker examination: – No abnormal pressure increase of the medial, central, and deep posterior compartments of the left and central compartment on the right foot. Serum CPK: – 687 IU/L (normal range for men, 35–232) Repeated CPK study and aldolase after rest from running for two weeks: – 669 IU/L and 9 (normal range, 1–8). Nerve conduction study – Normal Needle electromyography – At rest, abnormal sustained runs of positive sharp waves at virtually every needle site in all limbs studied – Motor unit potentials and recruitment were normal in all muscles. – Following immersion of his hands in cold water for approximately 4–5 minutes, a repeat needle examination of the patients first dorsal interossei in the hand showed a large amount of myotonic discharges. Thyroid function test, eye examination: – Normal Muscle biopsy specimen taken from quadriceps muscle: – No evidence of myotonia dystrophica, inflammation, and metabolic myopathy. FINAL/WORKING DIAGNOSIS Paramyotonia congenital. TREATMENT AND OUTCOMES Carbamazepine and mexiletine, both of which were discontinued secondary to reported adverse effects of subtle cognitive slowing. Phenytoin (400 mg q hs), which lessened the patients symptoms. The patient decided to give up running, as he was not able to maintain mileage high enough to compete successfully at an elite college level.

Use of a lateral offset short-leg walking cast before high tibial osteotomy.

The clinical results after high tibial osteotomy for the treatment of symptomatic varus gonarthrosis are unpredictable. Although preoperative gait analysis has been shown to be useful in predicting successful outcome after high tibial osteotomy, there are no readily available preoperative clinical tests for predicting success. The authors did a study to determine the effects of an offset short-leg walking cast as a potential predictor of clinical success after high tibial osteotomy. Specifically, the authors evaluated the effect of an offset short-leg walking cast on pain relief and changes in the peak external adduction moments in patients with symptomatic varus gonarthrosis indicated for high tibial osteotomy. Nineteen consecutive patients indicated for high tibial osteotomy were enrolled and completed the study. All patients had precast gait analysis to determine baseline parameters. Immediately after gait analysis, a short-leg lateral offset walking cast was applied and worn for 3 days to allow time for adaptation. Gait analysis then was repeated. Western Ontario and McMaster Universities Osteoarthritis Index pain scores were obtained before and after the cast was applied. The cast resulted in a mean reduction in pain of 53%, and a mean reduction in the peak external adduction moment of 36% in the 17 of 19 patients who tolerated the cast. The reduction in pain was correlated with the reduction in the peak adduction moment (r = 0.63). The authors conclude that an offset short-leg walking cast results in pain reduction that correlates with changes in external adduction moments about the knee. Therefore, an offset short-leg walking cast may prove to be an effective tool for predicting patients who ultimately will benefit from valgus high tibial osteotomy.