Introduction: Historically, off-loading forefoot neuropathic ulcers with a total contact cast has been an effective treatment method. However, large neuropathic ulcers located on the plantar aspect of the heel or midfoot have been resistant to the off-loading with total contact casting. Therefore, it is not uncommon for these ulcers to persist for several years leading to eventual infection and/or amputation.

Objective: To assesses a new and effective off-loading mode of treatment for hindfoot and midfoot ulcers. The device is composed of a fiberglass cast with a metal stirrup and a window around the ulcer.

Research, Design and Methods: A retrospective study of 14 diabetic and non-diabetic patients was performed. All had a single chronic planter hindfoot or midfoot neuropathic ulcer that failed to heal via the conventional methods. A fiberglass total contact cast with a metal stirrup was applied. A window was made over the ulcer so as to continue with daily ulcer care. The cast was changed every other week.

Results: The average duration of ulcer prior to application of the metal stirrup was 26 ± 13.2 months (range 7 to 52 months). The ulcer completely healed in 12 of the 14 patients (86%) treated. The mean time for healing was 10.8 weeks for the midfoot ulcers and 12.3 weeks for the heel ulcers. Complications developed in 4 patients: 3 developed superficial wounds and 1 developed a full thickness wound. In 3 of these 4 patients, local wound care was initiated and the Stirrup cast was continued to complete healing of the primary ulcer.

Conclusion: The fiberglass cast with a metal stirrup is an effective off-loading device for midfoot and hindfoot ulcers. It is not removable and does not depend on patient’s compliance. The window around the ulcer allows for daily wound care, drainage of secretions and the use of VAC treatment. The complication rate is comparable to that of Total Contact Casting.

Introduction: Preliminary data suggest that immobilization in external rotation may be effective in lowering the incidence of recurrence after first traumatic shoulder dislocation, with a zero reoccurrence rate reported at 15 months follow-up. The purpose of the present study was to ascertain whether this method could lower the incidence of recurrent dislocation in a young, very physically active population.

Methods: In an IRB approved prospective study, young males who sustained first traumatic shoulder dislocation were randomized to be treated for four weeks either using a traditional internal rotation brace or a new device which immobilizes the shoulder at 15 to 20 degrees of external rotation. Subjects were then treated according to a standard physical therapy protocol. Follow-up was done at five time points in the first year post dislocation. Subjects with clinically stable shoulders resumed full activity after three months. Differences in outcome were assessed by the chi square test.

Results: Thirty nine subjects participated in the study. Thirty of them were soldiers. Twenty four subjects were treated with external rotation braces. At follow-up of between 4 to 28 months, a new dislocation was documented in 8 of the 24 subjects immobilized in external rotation (33%) and in 5 of the 15 subjects immobilized in internal rotation (33 %). No statistical difference (p=1.0) was found between the instability rates of the two treatment groups.

Discussion: The present study indicates that even in a short-term follow-up the technique of immobilizing a first dislocation in external rotation was not effective in lowering the incidence of recurrent shoulder dislocations in a young, physically active population.

Introduction: When subjected to strain or strain rates are higher than usual, the bone remodels to repair microdamage and to strengthen itself. During the initial resorption phase of remodeling, the bone is transitorily weakened and microdamage can accumulate leading to stress fracture.

Methods: To determine whether short –term suppression of bone turnover using bisphosphonates can prevent the initial loss of bone during the remodeling response to high bone strain and strain rates and potentially prevent stress fractures, we conducted a randomized, double blind, placebo-controlled trial of 324 new infantry recruits known to be at high risk for stress fracture. Recruits were given a loading dose of 30 mg of residronate or placebo daily for 10 doses during the first two weeks of basic training and then a once a week maintenance dose for following 12 weeks. Recruits were monitored by biweekly orthopedic examinations during 15 weeks of basic training for stress fractures. Bone scans for suspected tibial and femoral stress fractures and radiographs for suspected metatarsal stress fractures were used to verify stress fracture occurrence.

Results: By the intension to treat analysis and per protocol analysis, there was no statistically significant difference in the tibial, femoral, metatarsal, or total stress fracture incidence between the treatment group and the placebo.

Discussion: We conclude that prophylactic treatment with residronate in a training population at high risk for stress fracture using a maintenance dosage for the treatment of osteoporosis does not lower stress fracture risk.