Non- or minimally displaced distal radius fractures in adult patients < 50 years of age : Three weeks of cast immobilisation versus one week of brace immobilisation: study protocol for a multicentre randomised controlled trial.

BACKGROUND: Currently, non- or minimally displaced distal radius fractures are treated by 3 to 5 weeks of cast immobilisation. Many patients with a distal radius fracture suffer from long-term functional restrictions, which might be related to stiffness due to cast immobilisation. Current literature indicates that 1 week of immobilisation might be safe; however, no level 1 evidence is available. This trial aims to compare 1 week of brace immobilisation with 3 weeks of cast immobilisation in patients with distal radius fractures that do not need reduction. METHODS: The aim of this trial is to evaluate the non-inferiority of 1 week of brace immobilisation in patients with non- or minimally displaced distal radius fractures. A two-armed single blinded multicentre randomised clinical trial will be conducted in three hospitals. Adult patients, between 18 and 50 years old, independent for activities of daily living, with a non- or minimally displaced distal radius fracture can be included in this study. The intervention group is treated with 1 week of brace immobilisation, and the control group with 3 weeks of cast immobilisation. Primary outcome is the patient-reported outcome measured by the Patient-Related Wrist Evaluation score (PRWE) at 6 months. Secondary outcomes are patient-reported outcome measured by the Quick Disabilities of the Arm, Shoulder and Hand score at 6 weeks and 6 months, PRWE at 6 weeks, range of motion, patient-reported pain score measured by VAS score, radiological outcome (dorsal/volar tilt, radial height, ulnar variance, presence of intra-articular step off), complications and cost-effectiveness measured by the EuroQol 5 Dimension questionnaire, Medical Consumption Questionnaire and Productivity Cost Questionnaire. DISCUSSION: This study will provide evidence on the optimal period of immobilisation in non-operatively treated displaced and reduced distal radius fractures. Both treatment options are accepted treatment protocols and both treatment options have a low risk of complications. Follow-up will be according to the current treatment protocol. This study will provide level 1 evidence on the optimal period and way of immobilisation for non- or minimally displaced distal radius fractures in adult patients. TRIAL REGISTRATION: ABR 81638 | NL81638.029.22 | www.toetsingonline.nl . 18th of October 2023.

Comparison of different immobilisation durations following open surgery for acute achilles tendon rupture: a prospective cohort study.

BACKGROUND: In recent decades, early rehabilitation after Achilles tendon rupture (ATR) repair has been proposed. The aim of this prospective cohort study was to compare different immobilisation durations in order to determine the optimal duration after open surgery for ATR repair. METHODS: This study included 1088 patients (mean age, 34.9 ± 5.9 years) who underwent open surgery for acute ATR repair. The patients were categorised into four groups (A, B, C, and D) according to postoperative immobilisation durations of 0, 2, 4, and 6 weeks, respectively. All patients received the same suture technique and a similar rehabilitation protocol after brace removal,; they were clinically examined at 2, 4, 6, 8, 10, 12, 14, and 16 weeks postoperatively, with a final follow-up at a mean of 19.0 months. The primary outcome was the recovery time for the one-leg heel-rise height (OHRH). Secondary outcomes included the time required to return to light exercise (LE) and the recovery times for the range of motion (ROM). Data regarding the surgical duration, complications, the visual analogue scale (VAS) score for pain, the Achilles tendon Total Rupture Score (ATRS), and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score were also collected. RESULTS: The recovery times for OHRH, LE, and ROM were significantly shorter in groups A and B than in groups C and D (P < 0.001). The VAS scores decreased over time, reaching 0 in all groups by 10 weeks. The mean scores in groups A and B were higher than those in the other groups at 2 and 4 weeks (P < 0.001), whereas the opposite was true at 8 weeks (P < 0.001). ATRS and the AOFAS Ankle-Hindfoot scale score increased across all groups over time, showing significant between-group differences from weeks 6 to 16 (P < 0.001) and weeks 6 to 12 (P < 0.001). The mean scores were better in groups A and B than in groups C and D. Thirty-eight complications (3.5%) were observed, including 20 re-ruptures and 18 superficial infections. All complications were resolved at the last follow-up, with no significant between-group differences. CONCLUSIONS: Immobilisation for 2 weeks after open surgery for ATR repair may be the optimal strategy for early rehabilitation with relatively minimal pain and other complications. TRIAL REGISTRATION: ClinicalTrials.gov (NCT04663542).

Comparison of C-MAC ® conventional blade, D-Blade ™ , and Macintosh laryngoscopes for endotracheal intubation in patients with simulated immobilization using manual in-line stabilization: A randomized trial.

BACKGROUND: A difficult airway is anticipated with cervical spine injuries (CSIs) as immobilization techniques such as manual in-line stabilization (MILS) are used, which distort the oro-pharyngeal-laryngeal axis. Video laryngoscopes (VLs) make difficult airway management easy, as they do not require axis alignment. The present study aimed to compare the total time taken by Macintosh laryngoscope (ML), conventional blade, and D-blade ™ of C-MAC ® VL in simulated CSI scenarios using MILS. METHODS: Ninety patients were randomly allocated into three groups: Group M (ML), Group C (conventional blade of C-MAC ® ), and Group D (D-blade ™ of C-MAC ® ) with MILS applied before intubation. Primary outcome was the total time taken for successful intubation, while secondary outcomes were to assess Cormack-Lehane (CL) grade, number of attempts, hemodynamic response, and associated complications. RESULTS: Total time for intubation in Group C was 23.40 ± 7.06 sec compared to 35.27 ± 6.53 and 47.27 ± 2.53 sec in groups D and M, respectively ( P < 0.001). CL-grade I was observed in 15/30 (50%) in Group M, 25/30 (83.3%) in Group C, and 29/30 (96.7%) in Group D. Group M reported 7/30 (23.3%) failed intubations, while none were observed in other groups. Hemodynamic parameters were significantly higher at 3 and 5 min in Group M. Postoperative sore throat was recorded in 12/30 (40%) in Group M compared to 3/30 (10%) in groups C and D each ( P value 0.037). CONCLUSION: C-MAC ® VL requires less time for intubation, provides better glottic view, and has higher success, with better attenuation of hemodynamic response and fewer complications compared to ML.

Construction of the discomfort assessment scale for immobilized trauma victims (DASITV).

BACKGROUND: Immobilization is an intervention widely administered to trauma victims and aims to reduce the victim's movements, ensuring the alignment of anatomical structures suspected of being injured. Despite the benefits of immobilization, it is responsible for the occurrence of pressure injuries, increases in intercranial pressure, pain, and discomfort. AIM: To develop an instrument to assess the discomfort caused by immobilization in trauma victims - Discomfort Assessment Scale for Immobilized Trauma Victims (DASITV). METHODS: A sequential mixed-methods design was used, divided into three distinct but complementary phases: (1) Conceptualization Phase - Construction of the DASITV; (2) Focus Group with a Panel of ten Technical Experts in the care of immobilized trauma victims to approve the DASITV proposal; (3) Acceptance of the scale proposal using a modified e-Delphi technique with 30 pre-hospital health professionals. RESULTS: The first phase led to the construction of a scale made up of two sub-scales. The Numerical Discomfort Scale assesses the level of discomfort the person reports from 0 to 10, with 0 being no discomfort and 10 being maximum discomfort. The second evaluation parameter gives the level of pressure in mmHg that the body exerts on the surface where it is immobilized. The combined interpretation of these two sub-scales leads to 4 different possibilities - ordered by level of severity. The Focus Group made it possible to improve the scale, with input from the group of experts and, using the modified e-Delphi technique, a wider group of professionals showed agreement with the DASITV. CONCLUSION: This study allowed us to propose a preliminary scale to assess the discomfort felt by victims of trauma caused by immobilization.

Reliability, clinical performance and trending ability of a pulse oximeter and pulse co-oximeter, in monitoring blood oxygenation, at two measurement sites, in immobilised white rhinoceros (Ceratotherium simum).

BACKGROUND: Monitoring blood oxygenation is essential in immobilised rhinoceros, which are susceptible to opioid-induced hypoxaemia. This study assessed the reliability, clinical performance and trending ability of the Nonin PalmSAT 2500 A pulse oximeter's and the Masimo Radical-7 pulse co-oximeter's dual-wavelength technology, with their probes placed at two measurement sites, the inner surface of the third-eyelid and the scarified ear pinna of immobilised white rhinoceroses. Eight white rhinoceros were immobilised with etorphine-based drug combinations and given butorphanol after 12 min, and oxygen after 40 min, of recumbency. The Nonin and Masimo devices, with dual-wavelength probes attached to the third-eyelid and ear recorded arterial peripheral oxygen-haemoglobin saturation (SpO2) at pre-determined time points, concurrently with measurements of arterial oxygen-haemoglobin saturation (SaO2), from drawn blood samples, by a benchtop AVOXimeter 4000 co-oximeter (reference method). Reliability of the Nonin and Masimo devices was evaluated using the Bland-Altman and the area root mean squares (ARMS) methods. Clinical performance of the devices was evaluated for their ability to accurately detect clinical hypoxemia using receiver operating characteristic (ROC) curves and measures of sensitivity, specificity, and positive and negative predictive values. Trending ability of the devices was assessed by calculating concordance rates from four-quadrant plots. RESULTS: Only the Nonin device with transflectance probe attached to the third-eyelid provided reliable SpO2 measurements across the 70 to 100% saturation range (bias - 1%, precision 4%, ARMS 4%). Nonin and Masimo devices with transflectance probes attached to the third-eyelid both had high clinical performance at detecting clinical hypoxaemia [area under the ROC curves (AUC): 0.93 and 0.90, respectively]. However, the Nonin and Masimo devices with transmission probes attached to the ear were unreliable and provided only moderate clinical performance. Both Nonin and Masimo devices, at both measurement sites, had concordance rates lower than the recommended threshold of ≥ 90%, indicating poor trending ability. CONCLUSIONS: The overall assessment of reliability, clinical performance and trending ability indicate that the Nonin device with transflectance probe attached to the third-eyelid is best suited for monitoring of blood oxygenation in immobilised rhinoceros. The immobilisation procedure may have affected cardiovascular function to an extent that it limited the devices' performance.

Different narcotic gases and concentrations for immobilization of ostrich embryos for in-ovo imaging.

In-ovo imaging using avian eggs has been described as a potential alternative to animal testing using rodents. However, imaging studies are hampered by embryonal motion producing artifacts. This study aims at systematically comparing isoflurane, desflurane and sevoflurane in three different concentrations in ostrich embryos. Biomagnetic signals of ostrich embryos were recorded analyzing cardiac action and motion. Ten groups comprising eight ostrich embryos each were investigated: Control, isoflurane (2%, 4%, and 6%), desflurane (6%, 12%, and 18%) and sevoflurane (3%, 5%, and 8%). Each ostrich egg was exposed to the same narcotic gas and concentration on development day (DD) 31 and 34. Narcotic gas exposure was upheld for 90 min and embryos were monitored for additional 75 min. Toxicity was evaluated by verifying embryo viability 24 h after the experiments. Initial heart rate of mean 148 beats/min (DD 31) and 136 beats/min (DD 34) decreased over time by 44-48 beats/minute. No significant differences were observed between groups. All narcotic gases led to distinct movement reduction after mean 8 min. Embryos exposed to desflurane 6% showed residual movements. Isoflurane 6% and sevoflurane 8% produced motion-free time intervals of mean 70 min after discontinuation of narcotic gas exposure. Only one embryo death occurred after narcotic gas exposure with desflurane 6%. This study shows that isoflurane, desflurane and sevoflurane are suitable for ostrich embryo immobilization, which is a prerequisite for motion-artifact free imaging. Application of isoflurane 6% and sevoflurane 8% is a) safe as no embryonal deaths occurred after exposure and b) effective as immobilization was observed for approx. 70 min after the end of narcotic gas exposure. These results should be interpreted with caution regarding transferability to other avian species as differences in embryo size and incubation duration exist.

Skeletal muscle immobilisation-induced atrophy: mechanistic insights from human studies.

Periods of skeletal muscle disuse lead to rapid declines in muscle mass (atrophy), which is fundamentally underpinned by an imbalance between muscle protein synthesis (MPS) and muscle protein breakdown (MPB). The complex interplay of molecular mechanisms contributing to the altered regulation of muscle protein balance during disuse have been investigated but rarely synthesised in the context of humans. This narrative review discusses human models of muscle disuse and the ensuing inversely exponential rate of muscle atrophy. The molecular processes contributing to altered protein balance are explored, with a particular focus on growth and breakdown signalling pathways, mitochondrial adaptations and neuromuscular dysfunction. Finally, key research gaps within the disuse atrophy literature are highlighted providing future avenues to enhance our mechanistic understanding of human disuse atrophy.

Influence of Chronic Forced Immobilization and Consumption of a High-Fat and High-Carbohydrate Diet Containing Cholesterol on Lipid and Cholesterol Metabolism in Male Wistar Rats.

We studied the effect of separate and combined influence of chronic forced physical activity reduction and high-fat and high-carbohydrate diet containing cholesterol on some indicators of carbohydrate, lipid, and cholesterol metabolism in growing male Wistar rats. Used combination of factors simulating a sedentary lifestyle and unhealthy diet did not have a synergistic effect on the selected biomarkers. On the contrary, the effect was antagonistic: body weight and appetite decreased and insulin resistance increased. The obtained results indicate certain prospects of hypercholesterolemia model using in preclinical studies of specialized food products to optimize the diet of individuals with disorders of carbohydrate and lipid metabolism.

Immobilization protocols for the treatment of cervical spine fracture: a scoping review.

BACKGROUND: Current protocols on cervical immobilization postcervical spine fracture are widely accepted in the acute rehabilitation of older adults, however consensus on its overall effectiveness remains lacking. PURPOSE: Summarize information from original studies on available cervical immobilization protocols following a cervical fracture and to answer the questions; Which types of study designs have been used to assess the effectiveness of these protocols? What are the currently reported cervical immobilization protocols following cervical fracture in adults? What is the effectiveness of these protocols? What adverse events are associated with these protocols? STUDY DESIGN: Scoping review was performed. PATIENT SAMPLE: Searches were performed on the following online databases from inception to February 23, 2023: EMBASE, MEDLINE, CINAHL, and CENTRAL. Databases were searched for articles pertaining to collar use post cervical spine fracture. OUTCOME MEASURES: Effectiveness of the cervical fracture immobilization protocols was the primary outcome, examined by various measures including union rates and disability indexes. METHODS: 4 databases were searched; EMBASE, MEDLINE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Cochrane Central Register of Controlled Trials (CENTRAL) beginning on February 23, 2023, where 5,127 studies were yielded and 32 were extracted based on studies of adults (≥18 years) with a diagnosis of a cervical fracture (C0-C7) managed with a rigid external orthosis to prevent instability and surgery (collar, or cervicothoracic orthosis). Risk of bias was assessed using the guidelines set out by the Joanna Briggs Institute. RESULTS: This scoping review yielded low-level prospective (18%) and retrospective (69%) cohort studies, case-control studies (3%), and case series (6%) from 1987 to 2022, patient age ranged from 14 to 104 years. Findings were difficult to summarize based on the lack of randomized controlled trials, leading to no clear conclusions drawn on the presence of standardized cervical immobilization protocols with no information on the duration of treatment or transition in care. Most included articles were retrospective cohort studies of poor to moderate quality, which have significant risk of bias for intervention questions. The effectiveness of these protocols remains unclear as most studies evaluated heterogeneous outcomes and did not present between-group differences. Mortality, musculoskeletal (MSK) complications, and delayed surgery were common adverse events associated with cervical collar use. CONCLUSION: This scoping review highlights the need for higher levels of evidence as there is currently no standardized immobilization protocol for cervical spine fractures as a primary treatment, the effectiveness of cervical immobilization protocols is unclear, and mortality, MSK complications, and delayed surgery are common adverse events. No sources of funding were used for this scoping review.

Immobilization during infant fluoroscopy: Pros and cons.

This article explores the practice of immobilization during fluoroscopy procedures for infants, discussing its advantages and disadvantages. The authors examine contrasting policies and thoughts on immobilization across different medical institutions. While some advocate for its routine use to minimize patient motion, enhance imaging quality, and decrease radiation exposure, others question its necessity and raise concerns about patient consent and parental distress. Ethical dilemmas are also discussed regarding patient autonomy and psychological impact on families. The authors advocate for a balanced approach, recognizing the utility of immobilization in certain clinical scenarios while still emphasizing patient-centered care. Ultimately, the article underscores the importance of institutional policies that prioritize both patient safety and ethical principles in pediatric radiology practices.

Air inflow into vacuum-type immobilization devices impacts setup errors.

We aimed to determine the impact of air inflow into vacuum-type immobilization devices (VIDs) on setup errors. We assigned 70 patients undergoing radiotherapy for head and neck cancer to groups V (n = 34) or N (n = 36) according to whether the VIDs were deflated weekly or not deflated during treatment, respectively. We calculated systematic errors (Σ) as the standard deviations (SDs) of mean errors, and random errors (σ) as the root mean square of SDs in each patient. We compared overall means (µ), SDs (SDoverall), random errors and systematic errors. We also measured temporary pressure changes in VIDs to determine the influence of pressure changes in VIDs on setup errors. The µ was within 0.20 mm and 0.2° in both groups, whereas SDoverall significantly differed between them. The SDoverall differed the most in the Roll axes of groups N (0. 87°) and V (0.58°). The Σ and σ values were lower in all axes of group V than in group N. Despite the initial deflation target of - 70 kPa, the pressure in VIDs reached - 5 kPa at the end of treatment. However, weekly deflation apparently maintained pressure at - 20 kPa. Effective pressure control in VIDs can reduce patient-by-patient variation and improve setup reproducibility for individual patients, consequently resulting in small variations among overall setup errors.

Changes in brain functional connectivity and muscle strength independent of elbow flexor atrophy following upper limb immobilization in young females.

Muscle disuse induces a decline in muscle strength that exceeds the rate and magnitude of muscle atrophy, suggesting that factors beyond the muscle contribute to strength loss. The purpose of this study was to characterize changes in the brain and neuromuscular system in addition to muscle size following upper limb immobilization in young females. Using a within-participant, unilateral design, 12 females (age: 20.6 ± 2.1 years) underwent 14 days of upper arm immobilization using an elbow brace and sling. Bilateral measures of muscle strength (isometric and isokinetic dynamometry), muscle size (magnetic resonance imaging), voluntary muscle activation capacity, corticospinal excitability, cortical thickness and resting-state functional connectivity were collected before and after immobilization. Immobilization induced a significant decline in isometric elbow flexion (-21.3 ± 19.2%, interaction: P = 0.0440) and extension (-19.9 ± 15.7%, interaction: P = 0.0317) strength in the immobilized arm only. There was no significant effect of immobilization on elbow flexor cross-sectional area (CSA) (-1.2 ± 2.4%, interaction: P = 0.466), whereas elbow extensor CSA decreased (-2.9 ± 2.9%, interaction: P = 0.0177) in the immobilized arm. Immobilization did not differentially alter voluntary activation capacity, corticospinal excitability, or cortical thickness (P > 0.05); however, there were significant changes in the functional connectivity of brain regions related to movement planning and error detection (P < 0.05). This study reveals that elbow flexor strength loss can occur in the absence of significant elbow flexor muscle atrophy, and that the brain represents a site of functional adaptation in response to upper limb immobilization in young females.

A prospective observational study evaluating two patient immobilisation methods in lung stereotactic radiotherapy.

PURPOSE: The main objective of this study was to assess inter- and intrafraction errors for two patient immobilisation devices in the context of lung stereotactic body radiation therapy: a vacuum cushion and a simple arm support. MATERIALS AND METHODS: Twenty patients who were treated with lung stereotactic body radiation therapy in supine position with arms above their head were included in the study. Ten patients were setup in a vacuum cushion (Bluebag™, Elekta) and ten other patients with a simple arm support (Posirest™, Civco). A pretreatment four-dimensional cone-beam computed tomography and a post-treatment three-dimensional cone-beam computed tomography were acquired to compare positioning and immobilisation accuracy. Based on a rigid registration with the planning computed tomography on the spine at the target level, translational and rotational errors were reported. RESULTS: The median number of fractions per treatment was 5 (range: 3-10). Mean interfraction errors based on 112 four-dimensional cone-beam computed tomographies were similar for both setups with deviations less than or equal to 1.3mm in lateral and vertical direction and 1.2° in roll and yaw. For longitudinal translational errors, mean interfraction errors were 0.7mm with vacuum cushion and -3.9mm with arm support. Based on 111 three-dimensional cone-beam computed tomographies, mean lateral, longitudinal and vertical intrafraction errors were -0.1mm, -0.2mm and 0.0mm respectively (SD: 1.0, 1.2 and 1.0mm respectively) for the patients setup with vacuum cushion, and mean vertical, longitudinal and lateral intrafraction errors were -0.3mm, -0.7mm and 0.1mm respectively (SD: 2.3, 1.8 and 1.4mm respectively) for the patients setup with arm support. Intrafraction errors means were not statistically different between both positions but standard deviations were statistically larger with arm support. CONCLUSION: The results of our study showed similar inter and intrafraction mean deviations between both positioning but a large variability in intrafraction observed with arm support suggested a more accurate immobilization with vacuum cushion.

Early rehabilitation vs. conventional immobilization in nonoperative treatment of proximal humeral fracture: a systematic review.

OBJECTIVE: Fractures of the proximal humerus (PHF) are commonly treated conservatively. Evidence suggests that a period of immobilization of one week or less may lead to some advantages compared to a traditional 3-4 weeks of immobilization. The purpose of this systematic review was to assess the clinical and radiological results in the case of early rehabilitation vs. delayed rehabilitation after PHF. MATERIALS AND METHODS: In July 2023, a literature search was carried out on the PubMed, MEDLINE, and Embase databases to identify all the randomized trials comparing early rehabilitation vs. delayed rehabilitation after PHF. The following data were extracted from each included study: patients' demographics, study design and level of evidence, follow-up times, treatment groups, evaluation scores adopted, and overall clinical and radiological findings. The quality of the trials was assessed using the Cochrane Risk of Bias Assessment. RESULTS: A total of 5 studies, including 378 patients and dealing with early vs. delayed rehabilitation in case of conservative treatment of PHF, were included in this study. Early rehabilitation was started within 1 week and consisted mainly of pendulum exercise and progressive passive mobilization. Early rehabilitation was associated with better pain and functional scores within the first 3 months in 3 studies. No difference in pain or function was reported at 6 months or longer follow-up, and no differences in complications rate were observed between early vs. delayed rehabilitation groups. CONCLUSIONS: This systematic review suggests that early mobilization within one week in case of conservative treatment of PHF leads to improved function recovery and reduced pain, especially in the first months of rehabilitation, without differences at longer follow-up and without increasing complications rate. Reducing immobilization time could accelerate function recovery and regaining independence in daily life activities.

Optimal immobilization position for conservative treatment of proximal humerus fractures by fracture type: a biomechanical cadaveric study.

In conservative treatment for proximal humerus fractures (PHFs), the immobilization position of the affected arm should not be determined uniformly. The aim of this study is to investigate the optimal immobilization position for conservative treatment of different types of PHFs. We hypothesized that the optimal position minimizing the deforming force in PHFs depends on the fracture components involved. PHF models involving either the surgical neck (SN) or greater tuberosity (GT) were created using 12 fresh-frozen cadaveric shoulders. In the SN model, the deforming forces on the pectoralis major muscle were measured in full adduction by increasing external rotation. In the GT model, the deforming force of the supraspinatus muscle was measured in neutral rotation by decreasing abduction, and the deforming force of the infraspinatus muscle was measured in full adduction by increasing internal rotation, respectively. In the SN model, the deforming force of the pectoralis major muscle increased significantly with external rotation from full internal rotation to neutral rotation (P = 0.006), indicating that the arm should be placed in full internal rotation. In the GT model, the deforming force of the supraspinatus muscle increased significantly with adduction from 45° of abduction to full adduction (P = 0.006); the deforming force of the infraspinatus muscle increased significantly with internal rotation from neutral rotation to full internal rotation (P = 0.006). These findings should be considered when placing the arm in abduction and neutral rotation so as to minimize the deforming force by either the supra or infraspinatus muscle. In conservative treatment for PHFs, the affected arm should be placed in a position that minimizes the deforming force on the fracture components involved.

Outcomes comparison of elastic bandage versus lower-leg cast immobilization after anterior talofibular ligament repair.

PURPOSE: The aim of this study was to compare the clinical outcomes between patients with chronic ankle instability (CAI) undergoing arthroscopic anterior talofibular ligament (ATFL) repair who received elastic bandage treatment and those who received lower-leg cast immobilization. METHODS: CAI patients with isolated ATFL injury undergoing arthroscopic ATFL repair from January 2017 and August 2019 were included in the study. The visual analogue scale (VAS) at rest and during activities, American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (Karlsson score), and time of returning to walk, walk normally, work and sports were evaluated preoperatively, and at 6 months and 12 months follow-up. RESULTS: A total of 41 patients were included in this study. Among them, 24 patients accepted lower-leg cast fixation, and the other 17 patients were immobilized with elastic bandage. Compared to patients with lower-leg immobilization, patients with elastic bandage fixation had significantly lower VAS during activities (P = 0.021) and higher AOFAS score (P = 0.015) at 12 months follow-up. The Karlsson score at 6 months follow-up were significantly higher in elastic bandage group than those in lower-leg group (P = 0.011). However, no significant difference was observed in time of returning to walk, work and sports between the two groups. CONCLUSION: Elastic bandage treatment was better than lower-leg cast immobilization in terms of eliminating pain symptom at 12 months follow-up, and improving ankle functional outcome at 6 months follow-up. Moreover, the present study emphasized that lower-leg cast immobilization offered no advantages in arthroscopic ATFL repair postoperative immobilization. STUDY DESIGN: Cohort study; Level of evidence, 3.

Long-term patient outcome is affected by deep venous thrombosis after Achilles tendon rupture repair.

PURPOSE: The aim of the study was to examine the impact of a deep venous thrombosis (DVT) on patient outcomes 3 years after Achilles tendon rupture (ATR) repair and if there were continued improvements between 1 and 3 years after surgery. A secondary aim was to determine risk factors associated with impaired patient outcomes in the long term. METHODS: This cohort study consisted of 181 ATR-repaired patients, from two large randomized clinical trials, who attended a 3-year follow-up evaluation. Patients were postoperatively randomized to two different weight-bearing interventions compared with immobilization in a below-knee plaster cast for 2 weeks. During immobilization, screening for DVT was performed with Doppler ultrasound. At 1 and 3 years postoperatively, functional- and patient-reported outcomes were evaluated by the validated heel-rise test and self-reported questionnaire, Achilles tendon Total Rupture Score (ATRS). RESULTS: In total, 76 out of 181 (42%) patients exhibited a DVT at the 2- or 6-week screening after ATR surgery. Suffering from a DVT during immobilization resulted at 3 years in a worse limb symmetry index (LSI) of heel-rise total work compared to patients without DVT, adjusted for age (DVT mean LSI 68% vs. no DVT 78%, p = 0.027). At 3 years, patients with a DVT during immobilization displayed lower ATRS (DVT median 88 vs. no DVT 93, p = 0.046), which was not significant after adjustment for age. However, patients with DVT exhibited an improvement in ATRS, LSI total work, and LSI maximum height between 1 and 3 years, which was not seen among patients without DVT. Independent risk factors for reduced patient functional outcomes at 3 years were older age, greater calf muscle hypotrophy, and suffering a DVT. CONCLUSIONS: DVT during immobilization affects patients' long-term functional outcomes 3 years after ATR repair. Clinicians should adequately address risk factors contributing to impaired patient outcomes in the long term, including calf muscle hypotrophy, DVT, and older age. LEVEL OF EVIDENCE: Level Ⅲ.

Environmentally friendly splints for limb immobilisation: a systematic review.

INTRODUCTION: Climate change is estimated to be the biggest global health threat of the 21st century, and has prompted calls to move away from processes in healthcare associated with high energy consumption and greenhouse gas emission. In musculoskeletal medicine, splints are widely used for limb immobilisation. These have typically been made from single-use materials such as gypsum, although in recent years purportedly environmentally friendly splints have been designed. In this systematic review, we set out to assess the clinical effectiveness of all commercially available environmentally friendly splinting materials, including Woodcast®. METHODS: The AMED (Allied and Complementary Medicine Database), CINAHL® (Cumulative Index to Nursing and Allied Health Literature), Cochrane Central Register of Controlled Trials, Embase®, Emcare® and MEDLINE® databases were searched to identify studies assessing the clinical effectiveness of biodegradable and environmentally friendly splints prior to paper review and data extraction. Formal quantitative synthesis was not possible owing to the substantial heterogeneity in the study designs and outcome measures. RESULTS: Six papers met the inclusion criteria, all investigating one particular splint material (Woodcast®). One was a case series, two were cohort studies and three were randomised controlled trials. Primary outcome measures were heterogeneous but the environmentally friendly splints were generally equivalent to traditional splint materials. Studies were mostly at a high risk of bias. CONCLUSIONS: There is limited research assessing 'green' splints in practice although the data suggest similarity with existing materials and no substantial safety concerns. Further scrutiny of the clinical effectiveness and environmental credentials of such splints is also required.

Temporary immobilization methods for closed low-energy ankle fracture-dislocations: comparative analysis of a retrospective cohort.

PURPOSE: Ankle fracture-dislocations (AFD) often necessitate staged management involving temporary external fixation (EF) due to mechanical instability or blistering. However, limited literature exists on the optimal temporary immobilization method for low-energy closed AFD. This study compared baseline patient and fracture characteristics, along with clinical and radiological outcomes between AFD initially immobilized with EF versus splinting. METHODS: A retrospective cohort study was conducted involving patients with AFD temporarily immobilized using EF or splinting, followed by definitive open reduction and internal fixation. Quality of reduction (QOR) was assessed for each patient post-initial immobilization and after the definitive surgery. RESULTS: The study encompassed 194 patients: 138 treated with a splint (71.1%) and 56 (28.9%) with EF. Secondary loss of reduction had occurred in three patients who were splinted (2.2%). The mean ages in the EF and splint groups were 63.2 and 56.1 years, respectively (p = 0.01). Posterior malleolus fracture (PMF) and blisters were more prevalent in EF patients (69.6% vs. 43.5% for PMF and 76.8% vs. 20.3% for blisters, respectively; p = 0.05 and p < 0.01). Postoperative complication rates were 8.9% for EF versus 10.9% for splinting (p = 0.69). Satisfactory final QOR was attained in 79.8% of patients treated with a splint versus 64.3% with EF (p = 0.02). CONCLUSION: Patients immobilized by EF presented with poorer baseline characteristics and had more unstable injuries. Nevertheless, postoperative complication rates were comparable. Thus, EF appears to be a valuable tool for standardizing outcomes in AFD patients with a less favorable prognosis.