Weight-bearing or non-weight-bearing after surgical treatment of ankle fractures: a multicenter randomized controlled trial.

PURPOSE: The goal of this study was to assess if unprotected weight-bearing as tolerated is superior to protected weight-bearing and unprotected non-weight-bearing in terms of functional outcome and complications after surgical fixation of Lauge-Hansen supination external rotation stage 2-4 ankle fractures. METHODS: A multicentered randomized controlled trial was conducted in patients ranging from 18 to 65 years of age without severe comorbidities. Patients were randomized to unprotected non-weight-bearing, protected weight-bearing, and unprotected weight-bearing as tolerated. The primary endpoint of the study was the Olerud Molander Ankle Score (OMAS) 12 weeks after randomization. The secondary endpoints were health-related quality of life using the SF-36v2, time to return to work, time to return to sports, and the number of complications. RESULTS: The trial was terminated early as advised by the Data and Safety Monitoring Board after interim analysis. A total of 115 patients were randomized. The O'Brien-Fleming threshold for statistical significance for this interim analysis was 0.008 at 12 weeks. The OMAS was higher in the unprotected weight-bearing group after 6 weeks c(61.2 ± 19.0) compared to the protected weight-bearing (51.8 ± 20.4) and unprotected non-weight-bearing groups (45.8 ± 22.4) (p = 0.011). All other follow-up time points did not show significant differences between the groups. Unprotected weight-bearing showed a significant earlier return to work (p = 0.028) and earlier return to sports (p = 0.005). There were no differences in the quality of life scores or number of complications. CONCLUSIONS: Unprotected weight-bearing and mobilization as tolerated as postoperative care regimen improved short-term functional outcomes and led to earlier return to work and sports, yet did not result in an increase of complications.

Split flexor pollicis longus tendon transfer to A1 pulley for correction of paralytic Z deformity of the thumb.

PURPOSE: To test the hypothesis that split flexor pollicis longus (FPL) transfer to the A1 pulley will correct a thumb paralytic Z deformity and that the transfer can be subjected to early postoperative active mobilization protocol. METHODS: In a prospective trial, 19 consecutive thumbs with ulnar or combined ulnar and median nerve paralysis received split FPL transfer to the thumb A1 pulley and active mobilization of transfer after 48 hours. Outcomes were assessed by correction of Z deformity during pinch, tendon transfer insertion pullout during early active mobilization, range of motion at the thumb metacarpophalangeal and interphalangeal joints, and postoperative treatment time. Data from historical records of 20 thumbs with split FPL to extensor pollicis longus (EPL) and 3 weeks' immobilization, treated before the prospective trial in the same institution, were used for comparison. RESULTS: All 19 thumbs with split FPL to A1 pulley achieved Z deformity correction at discharge from rehabilitation. There was no incidence of transfer insertion pullout during active mobilization, and patients were discharged 22 days earlier than the controls who received transfer of FPL to EPL insertion. Seventeen thumbs were available for follow-up more than 1 year after the index procedure. Fifteen thumbs retained deformity correction, and 2 had recurrence of Z deformity. The interphalangeal joint had considerably greater active motion following split FPL to A1 pulley compared with transfer of split FPL to EPL insertion. CONCLUSIONS: This study supports the hypothesis. Split FPL tendon transfer to thumb A1 pulley can correct paralytic thumb Z deformities and be mobilized early for transfer re-education. Improved interphalangeal joint active motion and reduced treatment time are added advantages over FPL transfer to the EPL insertion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Early active motion versus immobilization after tendon transfer for foot drop deformity: a randomized clinical trial.

BACKGROUND: Immobilization after tendon transfers has been the conventional postoperative management. Several recent studies suggest early mobilization does not increase tendon pullout. QUESTIONS/PURPOSES: To confirm those studies we determined whether when compared with immobilization early active mobilization after a tendon transfer for foot-drop correction would (1) have a similar low rate of tendon insertion pullout, (2) reduce rehabilitation time, and (3) result in similar functional outcomes (active ankle dorsiflexion, plantar flexion, ROM, walking ability, Stanmore score, and resolution of functional problems. METHODS: We randomized 24 patients with surgically corrected foot-drop deformities to postoperative treatment with early mobilization with active motion at 5 days (n = 13) or 4 weeks of immobilization with active motion at 29 days (n = 11). In both groups, the tibialis posterior tendon was transferred to the extensor hallucis longus and extensors digitorum communis for foot-drop correction. Rehabilitation time was defined as the time from surgery until discharge from rehabilitation with independent walking. The minimum followup was 16 months (mean, 19 months; range, 16-38 months) in both groups. RESULTS: We observed no case of tendon pullout in either group. Rehabilitation time in the mobilized group was reduced by an average of 15 days. The various functional outcomes were similar in the two groups. CONCLUSION: In patients with Hansen's disease, an early active mobilization protocol for foot-drop correction has no added risk of tendon pullout and provides similar functional outcomes compared with immobilization. Early mobilization had the advantage of earlier restoration of independent walking. LEVEL OF EVIDENCE: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Early postoperative active mobilisation versus immobilisation following tibialis posterior tendon transfer for foot-drop correction in patients with Hansen's disease.

After tibialis posterior tendon transfer surgery for foot-drop correction, the foot is traditionally immobilised for several weeks. To test the feasibility of early mobilisation after this procedure in patients with Hansen's disease, 21 consecutive patients received active mobilisation of the transfer starting on the 5th postoperative day. Transfer insertion strength was enhanced by Pulvertaft weave. The results were compared with a historical cohort of 21 patients receiving 4 weeks of immobilisation. The primary outcomes were active dorsiflexion, active plantar flexion and total active motion at the ankle, tendon-insertion pullout and time until discharge from rehabilitation with independent walking without aid. Assessments at discharge from rehabilitation and the last clinical follow-up at more than 1 year were compared between both groups. The Student's t-test was used to compare data between the groups, and 95% confidence interval of the difference between groups was determined. A p-value of 0.05 was considered statistically significant. The average follow-up was 22 months for both groups. There was no incidence of insertion pullout of the tendon transfer in either group. In addition, there was no difference in active dorsiflexion angle between the groups at discharge (mean difference: 2.2 degrees, p=0.22) and final assessment (mean difference: 2.3 degrees, p=0.42). The plantar flexion angles were similar in both groups at discharge (mean difference: 0.5 degrees, p=0.86) and final assessment (mean difference: 0.5 degrees, p=0.57). In addition, there was no difference in total active motion between the groups at discharge (mean difference: 2 degrees, p=0.54) and final assessment (mean difference: 1 degrees, p=0.49). The patients were discharged from rehabilitation with independent walking at 44.04+/-7.9 days after surgery in the mobilisation group compared to 57.07+/-2.3 days in the immobilisation group. This indicates a significant difference in morbidity (mean difference: 13 days, p<0.001) between the two groups. In summary, this feasibility study indicates that early active mobilisation of tibialis posterior transfer in patients with Hansen's disease is safe and has similar outcomes to immobilisation with a reduced time to independent walking, warranting the design of a controlled clinical trial to further substantiate this.

Outcome and prognostic factors in non-ambulatory Hansen Type I intervertebral disc extrusions: 308 cases.

Thoracolumbar intervertebral disc disease is the most common cause of caudal paresis in dogs. Whilst the pathogenesis of the extrusion has been widely studied, treatment protocols and prognostic factors relating to outcome remain controversial. Recent studies have examined a multitude of factors relating to time to regain ambulation after decompressive surgery. Most intervertebral disc herniations occur in the thoracolumbar region, causing upper motor neuron signs in the rear limbs, which are thought to have a more favourable prognosis compared to the lower motor neuron signs created by herniation of an intervertebral disc in the caudal lumbar region. Due to the potential disruption of the lumbar intumescence, lower motor neuron signs have been reported as having a less favourable prognosis. The purpose of this study was to evaluate the intervertebral disc space as a prognostic factor relating to ambulatory outcome and time to ambulation after decompressive surgery. Hansen Type I intervertebral disc extrusions were studied in 308 non-ambulatory dogs. Preoperative and postoperative neurological status, corticosteroid use, signalment, intervertebral disc space, postoperative physical rehabilitation, previous hemilaminectomy surgery, disc fenestration, return to ambulation, and time to ambulation were reviewed.

Prognostic indicators for time to ambulation after surgical decompression in nonambulatory dogs with acute thoracolumbar disk extrusions: 112 cases.

OBJECTIVES: To determine prognostic indicators for time to ambulation after surgical decompression in nonambulatory dogs with intact pain sensation and acute Hansen type-1 disk extrusions. STUDY DESIGN: Retrospective clinical study. ANIMALS: One-hundred twelve dogs with Hansen type-I disk extrusions that had decompressive hemilaminectomy or dorsal laminectomy. METHODS: All dogs had thoracolumbar disk extrusion and were nonambulatory with intact pain sensation at admission. Variables considered included age, weight, voluntary motor function at time of anesthetic induction, glucocorticoid use, times from onset of nonambulatory status to admission and surgical decompression, time in hospital to surgical decompression, anesthetic time, surgical time, number of contrast injections required to perform a diagnostic myelogram, postoperative pain sensation, and postoperative voluntary motor function. Time to ambulation was defined as the number of days from surgical decompression until the dog was able to stand and take a series of steps without assistance. RESULTS: One-hundred seven dogs (96%) were able to ambulate within 3 months. The mean time to ambulation was 12.9 days and was significantly shorter if dogs had postoperative voluntary motor function (7.9 days v 16.4 days, P <.0001). No other variable had a significant association with time to ambulation. CONCLUSIONS: Few perioperative variables have prognostic value for return to ambulation. Nonambulatory dogs with intact pain sensation and Hansen type-1 disk extrusions in the thoracolumbar spine that are treated with surgical decompression have a favorable prognosis. CLINICAL RELEVANCE: The presence of postoperative voluntary motor function is a favorable prognostic indicator for early return to ambulation.

Comparison of two conservative methods of treating an isolated fracture of the lateral malleolus.

We compared two conservative methods of treating Weber B1 (Lauge-Hansen supination-eversion 2) isolated fractures of the lateral malleolus in 65 patients. Treatment by immediate weight-bearing and mobilisation resulted in earlier rehabilitation than immobilisation for four weeks in a plaster cast. There was no significant difference in the amount of pain experienced or in the requirement for analgesics and early mobilisation was not associated with any complications. We therefore advocate early mobilisation for these stable ankle fractures.

The use of the Hansen-Street intramedullary nail in midshaft fractures of the femur.

A retrospective study was conducted on 75 consecutive femoral midshaft fractures treated with intramedullary nailing using the solid-diamond-shape Hansen-Street nail with an open technique. The average age of patients was 32.5 years. Road accidents accounted for 43 cases. The average operative time was 40 minutes. There were two systemic complications. No infection occurred. Fifty-six cases could be gathered for this study, with an average follow-up of 5 years; 19 were followed for at least 6 months. At 4 months, all the fractures were united except one. The average time to sound bony union was 4 months. There was no residual deformity in varus-valgus or in the sagittal plane. Malrotation was rare and did not exceed 5 degrees. Shortening of 2 cm was found in 3 patients where the fracture was comminuted. All followed patients returned to regular daily function. The use of the Hansen-Street nail in an open procedure is an accurate method for anatomic reduction. As opposed to closed techniques, the procedure proved in our hands to be simple and quick, without undue exposure to radiation of the surgical team, and without such other complications as nerve complications due to traction. The procedure with this device is indicated for mid-third fractures of the femoral shaft only.

Early functional treatment of supination-eversion stage-II ankle fractures: preliminary results.

The preliminary results of early functional treatment of 30 patients with a grade-II supination-eversion fracture of the ankle according to Lauge-Hansen are discussed. The treatment of all patients consisted of splint immobilization for one week, followed by the application of a functional brace (Push Brace Medium) and immediate full weight bearing and functional training. All fractures healed without complications. Ankle function, radiographic findings and anamnestic complaints were monitored. The loss of ankle function diminished to 3.2 degrees +/- 4.9 degrees plantar flexion and to 1.7 degrees +/- 5.3 degrees dorsal flexion after one year follow up, none of the patients had significant complaints of pain or swelling. Radiography showed consolidation with callus formation in all cases. The grade-II supination-eversion fracture is a stable fracture which allows early functional treatment with the support of a Push Brace Medium. This results in an inexpensive, simple and comfortable therapy. A prospective randomized clinical trial is necessary to show the advantages of functional treatment over cast immobilization. Long-term follow-up will have to ascertain the theoretic risk of posttraumatic osteo-arthritis.