Objectives. We aimed to examine the characteristics of deep venous flow in the leg in a cast and the effects of a wearable neuromuscular stimulator (geko; FirstKind Ltd) and also to explore the participants’ tolerance of the stimulator. Methods. This is an open-label physiological study on ten healthy volunteers. Duplex ultrasonography of the superficial femoral vein measured normal flow and cross-sectional area in the standing and supine positions (with the lower limb initially horizontal and then elevated). Flow measurements were repeated during activation of the geko stimulator placed over the peroneal nerve. The process was repeated after the application of a below-knee cast. Participants evaluated discomfort using a questionnaire (verbal rating score) and a scoring index (visual analogue scale). Results. The geko device was effective in significantly increasing venous blood flow in the lower limb both with a plaster cast (mean difference 11.5 cm/sec. -1. ; p = 0.001 to 0.13) and without a plaster cast (mean difference 7.7 cm/sec. -1. ; p = 0.001 to 0.75). Posture also had a significant effect on peak venous blood flow when the cast was on and the geko inactive (p = 0.003 to 0.69), although these differences were less pronounced than the effect of the geko (mean difference 3.1 cm/sec. -1. (-6.5 to 10)). The geko device was well tolerated, with participants generally reporting only mild discomfort using the device. Conclusion. The geko device increases venous blood flow in the lower limb, offering a potential mechanical thromboprolylaxis for patients in a cast. Cite this article: Bone Joint Res 2013;2:179–85

Introduction Ankle fusion presents a difficult problem in the presence of infection and poor bone stock. The Ilizarov method provides stability with remote fixation and allows weight bearing. Patients and method Fourteen consecutive patients were studied (10 males, 4 females). The mean age at onset of disease was 50 years (range 4–70). Thirteen of the patients had either clinical or radiological evidence of infection prior to ankle fusion surgery. Mean duration of problem was 52 months (range 8–372). Aetiology included traumatic arthritis in five, failed fusion in six, septic arthritis in one, infected ankle fracture non-union in one and avascular necrosis of talus in one. Local excision was followed by Ilizarov frame compression. Diagnosis of infection was based on microbiology and histology. Antibiotic treatment was continued until union. On radiological evidence of union the frame was dynamized and removed. A below-knee cast was applied for 4 weeks. Results At a mean period of 5 months, complete ankle fusion was found in 13/14 patients. One patient who had partial fusion of the ankle had recurrence of infection requiring amputation. Complications included pin site infection, lateral impingement, deep infection, hind-foot pain and neuroma at amputation site. Conclusion The Ilizarov ankle fusion is a reliable salvage procedure in difficult ankle problems

Purpose: Fractures of the distal tibia are high energy fractures, associated with marked soft-tissue trauma. Management of these fractures is challenging. The purpose of this study is to present our experience on the treatment of these fractures using hybrid external fixation, with or without open reduction and minimal internal fixation of the fibular fracture. Patients and Methods: Forty eight patients with a distal tibial fracture were admitted to the authors’ institution since 2005. There were 33 men and 15 women. According to AO there were 24 A, 10 B and 14 C fractures. The mean age of the patients was 45.6 years. Eight patients had an open pilon fracture; according to the Gustilo classification, 1 patient had a grade I, 5 patients had a grade II, and 2 patients had a grade III open fracture. In all patients, the pilon fracture was treated using hybrid external fixation; in 18 patients, open reduction and minimal internal fixation of the fibular fracture using plate and screws was also done. Results: Mean follow-up was 14 months (range, 9 to 36 months). In all patients, the mean duration of the application of the external fixation was 2.85 months, followed by the application of a below-knee cast. In 42 patients, radiographic evidence of union was observed at 3,6 months (range, 3 to 9 months). Time for union was different between patients with closed and grade I open fractures compared to patients with grade II and grade III open fractures (union at 3.5 and 6 months, respectively). There were 5 non-unions (10,4%) with 3 of them septic (6,25%). All three deep infections were low grade and occurred in open fractures.Delayed union was observed in 3 patients; in these patients, solid union of the fracture was observed at 7 months (range, 6 to 9 months). Pin track infection was observed in 7 patients (14.6%). Conclusion: Based on the present study, hybrid external is associated with satisfactory results for the management of distal tibial fractures with acceptable complications

In a prospective study, we reviewed 72 distal tibial fractures treated by percutaneous plating between July 1996 and June 2001. The patient’s mean age was 36 years (19 to 76). The majority of them were men. Seven fractures were open, with three of them Gustilo grade IIIA. Of 65 closed fractures, 15 were Tscherne grade III. All fractures were type 43A according to AO classification and were less than 5 cm from the ankle joint. Most of the fractures were group A3, with 22 group A3.3. Percutaneous plating was delayed for a mean of five days (2 to 15). Pre-contoured small fragment dynamic compression plate was placed on the medial aspect of the tibia under image intensifier control, through a short distal skin incision. On average, three distal and two proximal screws were inserted. Fibular fractures were stabilised in a similar fashion. Satisfactory fracture reduction was achieved in all cases. Postoperatively a below-knee cast was applied for six weeks and weight-bearing was permitted at eight weeks. Fracture healing occurred within 12 weeks (10 to 16). One patient needed bone grafting for treatment of delayed union. All patients had a functional range of ankle movement. In one patient, breakage of all screws was observed in a united fracture with shortening of the fracture. Local late infection where the skin was tented by skin screw heads occurred in eight patients and was resolved by debridement and hardware removal. Percutaneous plating of type A43 tibial fractures is safe, reproducible and successful and has few complications. The few adverse affects may well be eliminated by the use of newly-introduced low profile plates and screws

This prospective study included 236 open tibial fractures treated by unreamed AO nailing at three to four days after injury. Ten patients were lost to follow-up and 24 were excluded. We reviewed 202 consecutive open tibial fractures treated between January 1994 and December 2000. The mean age was 31 years (18 to 66) and 152 patients were men. There were 74 Gustilo grade-I, 66 grade-II, 32 grade-IIIA and 30 grade-IIIB fractures. The soft tissue injuries were managed by delayed primary closure, split skin graft or local flap. Most fractures were stabilised by unreamed nailing and statically locked. Below-knee casts were applied routinely for six weeks. Full weight-bearing was permitted and maintained 6 to 12 weeks after the operation. In 16 patients (8%), union was delayed, but union occurred within 12 to 30 weeks in 194 patients (96%). Nonunion was observed in eight fractures (4%). Functional union occurred in all patients. Ten (5%) had mild knee pain. Acceptable shortening was noted in seven cases (3.5%) and varus/valgus angulations in 12 (6%). In two patients the nail was too long and required exchange. Eight locking screws bent or broke. There was no sepsis but three wounds were superficially infected. Compartment syndrome developed in one patient. Twelve additional operations (exchange nailing, bone grafting, fibular osteotomy and dynamisation) were performed for delayed unions and nonunions. Seven additional operations were undertaken for surgical errors where the nail was too long, there was early excessive rotation, or there were missed locking screws. The delay in final treatment of open tibial fractures allows safe selection of patients for secure and cost-effective unreamed intramedullary nailing, with minor complications

Open reduction and internal fixation is the treatment of choice for patients with displaced fractures of the lateral and medial malleoli. Ideally, operative treatment restores sufficient stability to allow full mobility at the ankle joint. However, because of the necessity to protect the ankle from weight-bearing and other forces, we routinely immobilise the ankle in a below-knee cast because of our concerns about patient compliance. We carried out a prospective study to assess patient compliance with instructions on non-weight bearing following ORIF of ankle fractures. All 30 patients at our hospital who were treated for an ankle fracture over a 14 month period were included in our study. 22 of these underwent ORIF. A below knee cast was applied in all cases, and patients were instructed not to put any weight on the injured limb. A pressure sensitive film (Fuji Prescale Film, Sensor Products Inc., NJ, USA) was incorporated into the cast beneath the heel pad. Patients were informed that this was being done to measure the pressure within the cast, for the purposes of a trial. The cast was changed (including the pressure sensitive film) at two-week intervals over a six week period, providing three separate measurements of pressure on the heel. The sole of the cast was also examined, to complement the findings on the pressure film. At each visit, the patients level of pain was assessed using a visual analogue score, and the wound (if present) was examined. There was a remarkable variation in the amount of weight bearing performed by the patients in this study, but several trends could be observed. In most cases, patient compliance was greatest in the first four weeks following cast application, but patients tended to put significant weight on the limb in the 4–6 week period. Female patients tended to comply better than males. Patients with a history of alcohol or drug abuse complied poorly. Compliance was lower in those individuals with lower pain scores. Of interest, the degree of weight bearing did not significantly affect the radiological or clinical outcome at the 6-week mark in any case. We conclude that patient compliance with non-weight bearing is generally poor, although the effect of this poor compliance on the long-term outcome requires further study

Purpose: The purpose of this study is to report on the outcomes of children with ITW who received Botulinum A Toxin (BTX-A) as an adjunct treatment to manipulations/casting and maintenance protocol. Method: ITW severity was classified using gait analysis and defined by the absence of 1. st. ankle rocker, early 3. rd. rocker and an early and increased first ankle moment. 1. Subjects who met the three severity criteria received a single BTX-A injection into both gastrocsoleus and placed immediately in below-knee casts. Casts were changed two weeks later for a total casting period of four weeks. Subjects then entered a maintenance protocol involving use of night splints or articulated ankle-foot-orthotics. Outcome measures collected at all follow-up visits were ankle dorsiflexion with knee in 90° flexion (DFF) and extension (DFE). Results: Thirteen subjects with severe bilateral ITW participated. Subjects were followed for an average of 48 weeks (range 7 – 168 weeks) post BTX-A injection. Given the variability in subject outcomes, analyses and reporting were stratified according to subjects’ right and left feet. At day of BTX-A, right foot DFF/DFE were 1.7° ± 14.4 and −1.5° ± 13.0 and mean left DFF/DFE were −1.5° ± 12.8 and −6.5° ± 12.1. Immediate improvement following BTX-A (2 weeks) were seen as right foot DFF/DFE were 14.1° ± 10.0 and 6.3° ± 7.7 and left DFF/DFE were 9.6° ± 14.1 and 3.9° ± 10.6. At 4 weeks, right DFF/DFE were 16.6° ± 9.5 and 11.7° ± 9.1 and left DFF/DFE were 13.1° ± 8.6 and 7.3° ± 8.3. At the half-life of BTX-A (12 weeks), right DFF/DFE were 15.2° ± 12.2 and 10.8° ± 10.5 and left DFF/DFE were 15.8° ± 12.4 and 13.0° ± 11.6. At follow-up visits, correction was maintained as right DFF/DFE were 15.6° ± 9.1 and 10.4° ± 10.3 and left DFF/DFE were 16.9° ± 11.2 and 9.8° ± 10.7. Conclusion: This is the first study to show early outcomes (improved DFF/DFE) following BTX-A injections in ITW and provides evidence for obtaining and maintaining the correction from a single BTX-A injection over a short-term follow-up period

Introduction: Instrumental Distraction has opened a new window for management of resistant clubfoot. Classical Ilizarov assembly is typically used in patients over the age of two years. We applied the differential distraction technique using the UMEX fixator for ages varying from 6 months to 18 years. This method follows the Ilizarov principle of soft tissue response to tension stress. Materials and Methods: A retrospective review included 120 patients, treated between 1990 – 2001. The majority of the cases were “idiopathic” with 36 feet after failed surgery, 60 feet after failed manipulation and casting, and 11-neglected clubfeet. The non-idiopathic group included 5 feet in patients with arthrogryposis, 5 feet in patients with myelomeningocele, and 3 feet in patients with Streeter’s dysplasia. The UMEX frame spans three segments. The tibial segment consists of two wires trans-fixing the tibia in its proximal third and an axial pin to prevent rocking of the frame. The metatarsal segment incorporates a transfixing pin and two half pins to maintain the transverse arch of the foot. The calcaneal segment includes two transfixing wires and and an axial pin. The three segments are then linked together by a system of clamps, rods and distractors to create the UMEX clubfoot frame. Treatment extends through three stages: Reduction, Retention and Remodeling. The distractors apply differential distraction, and the various deformities are corrected simultaneously. After r eduction is completed the frame is left in a “holding” mode for six more weeks. Thereafter, the assembly is removed and a well-molded below-knee cast is applied for a period of 8 – 12 weeks with monthly cast changes. During the remodeling phase, night splints and walking boots are used for a period of one year. Results: Results were assessed on the basis of the HJD functional rating system. Results were measured at 6-month intervals for 2 years and then yearly. We obtained excellent results in 34.4%; good, in 38.3%; fair, in 16.7% and poor, in 10.8% of the cases. Discussion: The classical Ilizarov method of deformity correction is a constrained assembly applying distraction – compression forces across a predefined hinge. The unconstrined UMEX assembly makes no such demands and correction is achieved at the natural joints. The technique of differential distraction avoids any compression and, as seen in the long-term follow-up, has no ill effects on the growing foot. There is no age limit for use of the system; in older patients, however, incomplete remodeling leaves residual bone deformities. If there is residual foot deformity with completion of the treatment, only limited open surgery is required. In our hands, the use of differential distraction produced functionally serviceable and cosmetically acceptable correction of clubfoot. Conclusion: Our experience demonstrates the effectiveness of differential distraction using the UMEX mini external fixator. This is an excellent technique for correction of complex deformities of the foot and ankle at any age and in the future may replace, to a large degree, the need for open clubfoot surgery

Aims

To systematically review the efficacy of split tendon transfer surgery on gait-related outcomes for children and adolescents with cerebral palsy (CP) and spastic equinovarus foot deformity.

Between 1997 and 2002, seven talipes equino varus deformities in six patients were treated using gradual distraction and correction with the Ilizarov external fixator. Three patients had poliomyelitis, four patients had neglected clubfeet and two patients had relapsed club-feet. The mean age of patients was 13.3 years (5 to 21) and the mean duration of fixator application was 3.25 months. When the plantigrade position was achieved the fixator was removed and a below-knee walking cast was applied. Four months after fixator removal, additional bony correction surgery (triple arthrodesis) was done in three patients. At the time of fixator removal, a plantigrade foot was achieved in all patients. The mean follow-up time from surgery was 26 months. Pin-tract sepsis in two patients was treated effectively with oral antibiotics. Other complications included meta-tarsophalangeal subluxation from flexor tendon contractures in one foot. There have been no recurrences of deformities. Compared to preoperative status, gait was subjectively improved in all patients. Correction of the deformity in the patients who had a triple arthrodesis of the foot was achieved with less bone loss than in patients who had undergone a primary triple arthrodesis. These results suggest that treatment with Ilizarov frames is effective in the management of neglected and relapsed clubfoot deformities

The most important determinant of treatment of malleolar fractures is stability. Stable fractures have an intact deep deltoid ligament and do not displace with functional treatment. If the deep deltoid/medial malleolar complex is disrupted, the talus is at risk of displacement. We developed clinical criteria for potential instability and applied them to a prospective series of patients. Criteria included: a medial clear space of < 4mm; medial tenderness, bruising or swelling; a fibular fracture above the syndesmosis; a bimalleolar or trimalleolar fracture; an open fracture; a high-energy fracture mechanism. Patients with a medial clear space of < 4mm and none of these criteria were considered to have stable fractures, while those with a medial clear space of > 4mm were considered to have a displaced fracture. We studied 152 consecutive skeletally mature patients with undisplaced, potentially unstable malleolar fractures treated by the senior author between 1st January 1998 and 31st December 2007. Patients were treated in a below-knee walking cast (136 patients) or a functional ankle brace (16 patients) for six weeks. Weight bearing was encouraged throughout. Weight bearing radiographs were obtained at one week and six weeks. Displacement was defined as talar displacement with a medial clear space > 4mm. Demographic, clinical and radiological data were collected prospectively. There were 88 male and 64 female patients, with a median age of 43 years. Criteria for possible instability were: medial tenderness, 115 patients; proximal fibular fracture, 29 patients; bimalleolar fracture, 17 patients; other criteria, 15 patients. Three fractures displaced (risk of displacement 2.0%, 95% CI 0.4–5.7%). All displaced within the first week and were treated by open reduction and internal fixation. One bimalleolar fracture developed a symptomatic medial malleolar non-union which was treated by percutaneous screw fixation (risk of non-union 5.9%, 95% CI 0.1%–28.7%). All the other fractures achieved clinical union by 8 weeks

Objectives

The incidence of acute Achilles tendon rupture appears to be increasing. The aim of this study was to summarize various therapies for acute Achilles tendon rupture and discuss their relative merits.