Walking boot

Abstract: Objectives At our institution, a standardized protocol using magnetic resonance imaging (MRI) to evaluate ankle stability and need for surgery following a positive manual stress test for isolated lateral malleolus fractures has been used. The purpose of this study was to evaluate the results using this standardized protocol. Design Retrospective review. Setting University teaching hospital. Patients : Twenty-one patients who had a positive ankle stress test (>or=5 mm clear space widening) after isolated Weber B lateral malleolus fracture were further evaluated by MRI to determine the status of the deep deltoid ligament. Intervention If the MRI showed the deltoid ligament was completely disrupted, the patient was advised to have operative ankle repair. However, if the MRI demonstrated that the deep deltoid was intact or only partially disrupted, the patient was treated nonoperatively in a walking boot with weightbearing as tolerated ambulation. Main outcome measurement Patients were followed until fracture union and contacted at 12-month minimum follow-up to determine outcomes by radiographic evaluation, health related quality of life (HRQOL) based on Short Form (SF)-36 results and functional outcomes based on the American Orthopaedic Foot and Ankle (AOFAS) and patient report of treatment satisfaction. Results Twenty-one patients had an MRI after a positive ankle stress test and comprised the study group. There were 12 men and 9 women with an average age of 27 years (range, 16-62 years). Absolute medial clear space measurement on stress testing ranged from 5 to 8 mm. In all, 19 of 21 patients (90%) had evidence of partially torn deep deltoid ligament on MRI and were treated nonoperatively, whereas two patients had MRI findings of a complete deep deltoid injury and underwent surgical treatment. There were no statistically significant correlations between the medial clear space measurements and MRI documentation of complete deltoid ligament rupture. All fractures united without evidence of residual medial clear space widening or posttraumatic joint space narrowing. Of the 15 patients who were available for 1 year minimum follow-up and agreed to come back for clinical and radiographic evaluation, 14 had an AOFAS score of 100, with the remaining patient having a score of 85. HRQOL based on SF-36 results indicated all patients were above or at normal levels, and all patients reported that they were satisfied with their treatment; 93% (14/15) indicated that they would make the same treatment decision again. Conclusions Using our protocol, we were able to identify and provide effective nonoperative care to 19 patients who otherwise might have underwent operative treatment after an isolated lateral malleolus fracture. Further work is needed to identify the subset of patients who could be treated nonoperatively without a need for MRI scanning.

Abstract: Treatment of Charcot foot osteoarthropathy has emerged as a major component of the American Orthopaedic Foot and Ankle Society (AOFAS) Diabetes 2000 Initiative. A two-part survey described treatment patterns and current footwear use of patients with Charcot osteoarthropathy of the foot and ankle. In the first part, 94 consecutive patients with a history of Charcot foot and ankle presenting for care were questioned on their foot-specific treatment and current footwear use. A history of diabetic foot ulcer was given by 39 (41%) patients, and an infection had been present in a foot of 20 (21%) patients. The initial treatment of the Charcot foot and ankle had been a total contact cast in 46 (49%) patients, and a pre-fabricated walking boot in 19 (20%). Charcot related surgery had consisted of 76 procedures in 46 (49%) patients. Sixty-three (67%) patients were currently using accommodative footwear (depth-inlay shoes in 46 [49%], custom shoes in 10 [11%], and CROW in 7 [7%] patients), and 72 (77%) were currently using custom accommodative foot orthoses. The second part of this study consisted of a questionnaire completed by 37 orthopaedic surgeons (members of AOFAS) interested in forming a Charcot Study Group. They treated an average of 11.8 patients having Charcot foot or ankle per month. Thirty (81%) used the Semmes-Weinstein 5.07 monofilament as a screening tool for peripheral neuropathy. For treatment of Eichenholtz Stage I, 29 (78%) used a total contact cast and 15 (41%) allowed weightbearing; for Stage II, 30 (81%) physicians used a total contact cast and 18 (49%) allowed weightbearing. Although the literature contains uniform recommendations for immobilization and non-weightbearing as treatment for the initial phases of Charcot arthropathy, the results of this benchmarking study reveal that currenl treatment is varied.

Abstract: Background: Complications including delayed and nonunions, and extensive time nonweightbearing with conservative treatment of fifth metatarsal Jones fractures, have led authors to recommend surgical fixation for this fracture in athletes who wish to return to activity quickly. The optimal surgical procedure, however, has not been determined. The purpose of this study was to evaluate the effectiveness of 5.5-mm cannulated screw fixation for fifth metatarsal stress fractures in athletes and compare them to an earlier cohort treated with a 4.5mm screw. Materials and Methods: Twenty athletes were treated surgically with a 5.5-mm cannulated screw and postoperatively wore a removable walking boot, applied cold compression, initiated immediate range of motion, and used crutches for 1 week. Fractures were evaluated for clinical and radiographic healing. These findings were compared to a group that used 4.5-mm screws. Results: Average radiographic healing was 96.7% and all fractures healed clinically. Athletes ret...

Abstract: The purpose of this study was to evaluate the clinical outcome of patients treated with limited immobilization and early motion after repair of acute Achilles tendon ruptures. Thirteen consecutive patients with complete ruptures of the Achilles tendon were identified, repaired, and rehabilitated with early motion starting an average of 10 days after surgery. Active range of motion was begun at an average of 23 days and weightbearing in a walking boot was started at an average of 3.5 weeks after surgery. The average length of follow-up was 27 months. Twelve of 13 patients returned to running activities in an average of 3 months. All 12 patients who participated in lateral motion activities before their injury returned to similar activities in an average of 7 months. The patients rated their overall status at an average of 93% of their preinjury level. Follow-up Cybex testing demonstrated plantarflexion strength averaging 92%, plantarflexion power averaging 88%, and plantarflexion endurance averaging 88% of the nonindexed extremity. Early range of motion after Achilles repair is safe and there is no increased risk of rerupture in compliant patients. The patients achieved good return of plantarflexion strength, power, and endurance.