Compared to conventional physiotherapy, does the use of an ankle trainer device after Weber B ankle fracture operation improve outcome and shorten hospital stay? A randomized controlled trial.

OBJECTIVE: To compare the functional outcomes and length of hospital stay for patients treated with conventional physiotherapy compared to a new ankle trainer device after Weber B ankle fractures. DESIGN: The patients were randomized, and then followed up at 3, 6, 12 and 52 weeks by a blinded physiotherapist. SETTING: This study was done at a level 1 trauma centre. SUBJECTS: One hundred and forty consecutive patients with Weber B ankle fractures that were operated on were screened for eligibility, of whom 113 were included in the study. INTERVENTIONS: Conventional physiotherapy with stretching exercises, using a non-elastic band or using new ankle trainer. MAIN MEASURES: Outcomes were evaluated with Olerud-Molander ankle score, Visual analogue scale for pain and ankle dorsiflexion at 3, 6, 12 and 52 weeks follow-up. Time of hospitalization and complications were registered. RESULTS: Superior Olerud-Molander ankle scores were observed at three weeks follow-up in the ankle trainer group 40.9 (10.8), compared to the conventional group 35.3 (14.2) (P = 0.021). At one-year follow-up, there was no difference between the groups (P = 0.386). The ankle trainer group had a shorter hospital stay with a mean 2.6 days (0.98) compared to 3.2 days (1.47) in the conventional group (P = 0.026). CONCLUSION: The patients who were treated with the new ankle trainer device recovered more rapidly, evaluated by the Olerud-Molander ankle score and had a shorter stay in hospital compared to the conventional physiotherapy group. No between group differences could be observed at long-term follow-up.

Posterior tibial tendon transfer improves function for foot drop after knee dislocation.

BACKGROUND: Knee dislocation may be associated with an injury to the common peroneal nerve with a subsequent foot drop. Previous studies have demonstrated good functional results after posterior tibial tendon transfer in patients with foot drop. No studies, to our knowledge, have focused exclusively on knee dislocation as the cause of common peroneal nerve injury leading to foot drop. QUESTIONS/PURPOSES: We determined the percentage of patients developing common peroneal nerve paresis after knee dislocation, the symptom improvement rate in these patients, and patient-reported outcomes (American Orthopaedic Foot and Ankle Society [AOFAS] ankle-hindfoot score), ankle dorsiflexion strength, and ROM in patients with no symptom improvement treated with posterior tibial tendon transfer. METHODS: Two hundred forty-seven patients with knee dislocation, defined as an injury to both the ACL and PCL with an additional injury to the lateral and/or medial ligaments (Schenck Classification II to IV), were registered in a single institution's database between 1996 and 2011. The database was queried for the frequency of documented injuries to the common peroneal nerve and, among those, the frequency of spontaneous resolution after this injury. Patients demonstrating no active dorsiflexion 12 months after injury generally were offered posterior tibial tendon transfer. Postoperatively, patients were evaluated for AOFAS score, ankle dorsiflexion strength, and ROM. RESULTS: Forty-three patients (17%) had a common peroneal nerve paresis at admission. At 1-year followup, 15 of 43 patients (35%) had experienced symptom improvement. One patient experienced spontaneous improvement later than 1 year after injury. One patient was lost to followup. A below-knee amputation was performed in one patient due to the initial trauma. Seven patients were satisfied with their function using a brace or had medical contraindications to surgical treatment, while four patients refused the proposed operation with a tendon transfer, leaving 14 patients treated with posterior tibial tendon transfer. In the 12 patients available for evaluation, mean AOFAS score was 91 of 100. Mean (± SD) dorsiflexion strength was 118 (± 55) Nm on the operated side and 284 (± 94) Nm on the unaffected side (p < 0.001). Mean ROM was 67° (± 15°) on the operated side and 93° (± 14°) on the unaffected side (p < 0.001). CONCLUSIONS: Based on these findings, we recommend posterior tibial tendon transfer for treatment of foot drop that persists at least 1 year after knee dislocation. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Outcomes After Proximal Medial Gastrocnemius Recession and Stretching vs Stretching as Treatment of Chronic Plantar Fasciitis at 6-Year Follow-up.

BACKGROUND: Evidence from prospective short-term studies suggest that proximal medial gastrocnemius recession is a safe and efficient procedure to treat chronic plantar fasciitis resistant to nonoperative treatment. The aim of this study was to evaluate the long-term clinical outcomes of proximal medial gastrocnemius recession and stretching compared to a stretching exercise protocol for patients with chronic plantar fasciitis and an isolated gastrocnemius contracture (IGC). METHODS: Forty patients with plantar fasciitis lasting more than 1 year were prospectively randomized to a home stretching exercise program only, or to proximal medial gastrocnemius recession in addition to the stretching program. Clinical and functional data in this study were obtained at baseline and 6-year follow-up. The main outcome was the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score. Secondary outcomes were the visual analog scale (VAS) for pain, the Manchester Oxford Foot Questionnaire (MOxFQ), ankle dorsiflexion, and Achilles complex performance. RESULTS: Thirty-three of 40 patients completed the 6-year follow-up. Seven patients had crossed over from nonoperative treatment to operative treatment. At 6 years, the operative group demonstrated significantly better outcomes with AOFAS (88.9 vs 78.6, P = .012), for pain measured by VAS (2.5 vs 5.5, P < .001) and with the MOxFQ total score (24.4 vs 45.9, P = .05) (per protocol analysis excluding crossovers). No between-group differences were observed for ankle dorsiflexion or Achilles complex performance at 6 years. CONCLUSION: This study demonstrates that the improved function and reduced level of pain by proximal medial gastrocnemius recession and stretching is better compared to stretching alone after 6 years of follow-up for patients with chronic plantar fasciitis and a concomitant isolated gastrocnemius contracture. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Proximal Medial Gastrocnemius Recession and Stretching Versus Stretching as Treatment of Chronic Plantar Heel Pain.

BACKGROUND:: Plantar heel pain is a common disorder that can lead to substantial pain and disability. Gastrocnemius recession has been described as an operative treatment option, but there is a lack of prospective clinical and biomechanical outcome data. The aim of this study was to evaluate the clinical and biomechanical outcomes of gastrocnemius recession and stretching compared with a stretching exercise protocol for patients with plantar heel pain lasting more than 12 months. METHODS:: Forty patients with plantar heel pain lasting more than 1 year were randomized to a home stretching exercise program only or to surgery consisting of a proximal medial gastrocnemius recession in addition to stretching exercises. The main outcome was the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score at 12 months. Secondary clinical outcomes were the Short Form-36 (SF-36) and visual analogue scale (VAS) pain scores. The biomechanical outcome parameters were ankle dorsiflexion, Achilles function evaluated by a test battery with 6 independent tests, and plantar pressure evaluated by pedobarography. All data were obtained at baseline and at 12-month follow-up. RESULTS:: The AOFAS score increased from 59.5 (42-76) to 88.0 (50-100; P < .001) for the operative group and from 52.5 (37-73) to 65.5 (31-88; P = .138) for the nonoperative group. The AOFAS, VAS pain, and SF-36 scores were significantly better in the operative compared with the nonoperative group at 12-month follow-up ( P < .05). Ankle dorsiflexion increased from 6 degrees (-3 to 15) to 10.5 degrees (0 to 23; P < .001). No between-group difference was observed for Achilles function at follow-up. The average forefoot plantar pressure for the operative group increased from 536 KPa (306-708) to 642 KPa (384-885) at follow-up ( P < .001). CONCLUSION:: Proximal medial gastrocnemius recession with a stretching program was a safe and efficient method of treating chronic plantar heel pain. LEVEL OF EVIDENCE:: Level 1, randomized clinical trial.

Validation of a New Device for Measuring Isolated Gastrocnemius Contracture and Evaluation of the Reliability of the Silfverskiöld Test.

BACKGROUND: Important aspects on the diagnostics of isolated gastrocnemius contractures (IGCs) have been poorly described. This study was designed to validate a new ankle range of motion (ROM) measuring device for diagnosing an IGC. In addition, we wanted to investigate the reliability of the clinical Silfverskiöld test. METHODS: Twelve health care personnel (24 feet) were examined by 4 testers on 3 different occasions for the reliability testing of the new ankle ROM measuring device. The same participants were examined using the Silfverskiöld test to examine the reliability of the clinical test. Eleven patients (15 feet) with IGC were examined before gastrocnemius recession, immediately after surgery, and 3 months after surgery to examine the validity and responsiveness of the ankle ROM device. RESULTS: An intraclass correlation coefficient (ICC) >0.85 was found for both inter- and intrarater reliability for the new ankle ROM device. The device confirmed an IGC in 13 of 15 feet before surgery and 3 of 13 feet at 3-month follow-up. At baseline, the measured ankle dorsiflexion was median 3 degrees with the knee in extension, which increased to 10 degrees ( P < .001) immediately after surgery and 12 degrees ( P = .003) at 3-month follow-up. ICC values of 0.230 to 0.791 were observed for the inter- and intrarater reliability testing of the clinical Silfverskiöld test. CONCLUSION: The new ankle ROM measuring device was reliable and responsive for detecting IGC. The Silfverskiöld test had poor inter- and intrarater reliability. Level of evidence Level II, prospective cohort study.