Balance in single-limb stance after surgically treated ankle fractures: a 14-month follow-up

The Effects of Various Cognitive Tasks Including Working Memory, Visuospatial, and Executive Function on Postural Control in Patients With Anterior Cruciate Ligament Injury

Anterior cruciate ligament (ACL) rupture can impair balance performance, particularly during cognitive motor dual-tasks. This study aimed to determine the effects of various modalities of cognitive load (working memory, and visuospatial and executive function) on postural control parameters in individuals with ACL injury. Twenty-seven ACL-injured and 27 healthy participants were evaluated doing different cognitive tasks (silent backward counting, Benton's judgment of line orientation, and Stroop color-word test) while standing on a rigid surface or a foam. Each task was repeated three times and then averaged. Center of pressure variables used to measure postural performance included sway area and sway velocity in anterior-posterior and medial-lateral directions. Cognitive performance was also assessed by calculating errors and the score of cognitive tasks. A mixed model analysis of variance for center of pressure parameters indicated that patients had more sways than the healthy group. The interaction of group by postural difficulty by cognitive tasks was statistically significant for cognitive errors (p < .01), and patients with ACL injury indicated more cognitive errors compared to healthy controls while standing on the foam. The main effect of cognitive task was statistically significant for all postural parameters, representing reduced postural sways in both groups with all cognitive tasks. However, ACL-injured patients showed more cognitive errors in difficult postural conditions, suggesting that individuals with ACL injury may prioritize postural control over cognitive task accuracy and adopt the posture-first strategy to maintain balance under dual-task conditions.

An investigation into the frequency and risk factors of low back pain following surgical treatment of isolated calcaneal fractures

OBJECTIVE

This study aimed to determine the frequency of low back pain after calcaneal fractures treated with open reduction internal fixation (ORIF) and the risk factors that cause this condition.

METHODS

Thirty-one patients (27 males and 4 females) who underwent surgery for a unilateral calcaneal fracture between 2016 and 2020 and had no complaints of low back pain before fracture surgery were included in the study. The patients were divided into 2 groups: those who developed low back pain after the operation and those who did not. Patients were evaluated with the Life Quality Short Form SF-36, the Oswestry Disability Index (ODI), and American Orthopedic Foot-Ankle Association Score (AOFAS). Sanders' fracture type, joint range of motion (ROM) measurements of injured and uninjured limbs, maximal isometric muscle strength measurements, balance on 1 leg with pedobarographic measurements, and walking time were evaluated. The obtained data were compared among the 2 groups.

RESULTS

Low back pain was observed in 71% of the patients and was detected after an average of 6 months from the operation. In ODI, 59.1% of the patients reported that low back pain limited their lives slightly. Patients with low back pain have lower AOFAS scores and worse SF-36 physical functionality than those without low back pain (P < .001, P=.016). Balance time on 1 foot in pedobarographic measurements, foot in ROM, ankle in ankle active, passive plantar flexion, inversion, active hip, passive internal, external rotation, muscle is the foot eversion force. In these measurements, the values of the injured side are intact. It was statistically significantly lower than the other side (interaction P < .1).

CONCLUSION

Low back pain may occur after unilateral calcaneal fractures treated by ORIF. This may be caused by decreased angles of ankle dorsi and plantar flexion, foot inversion, hip abduction, and internal and external rotation. In the rehabilitation program, not only the ankle region but also the hip joint of the affected side should be included, and the kinetic chain that describes the interaction mechanism of the human body should not be forgotten.

LEVEL OF EVIDENCE

Level IV, Prognostic Study.

Factors Associated With Long-Term Quadriceps Muscle Function After Surgical Fixation of Lower Extremity Fractures

OBJECTIVE

The long-term performance of the quadriceps femoris muscle and physical function following surgical repair of a lower extremity fracture remains largely undefined. The purpose of this study was to investigate between-limb differences in quadriceps performance 12 months after surgical fixation of a lower extremity fracture. It was hypothesized that the injured limb would be significantly weaker, have a lower rate of torque development (RTD), and that there would be a reduced step-down performance compared to the uninjured limb 12 months after surgery. Additionally, this study sought to identify demographic, surgical, and psychological factors associated with poor quadriceps function 12 months after surgery.

METHODS

Quadriceps performance was measured bilaterally in 95 participants (49 female), aged 42 (SD = 14.5) years, 12 months after surgical fixation of a lower extremity fracture. Isometric quadriceps strength and RTD were quantified using isometric dynamometry, and a timed step-down test was used to evaluate quadriceps performance. Independent predictor variables from the time of surgery were extracted from participants' medical records. Kinesiophobia was screened at the time of testing. Wilcoxon signed-rank tests and linear regression analyses were used to assess between-limb differences in quadriceps performance and to determine factors associated with quadriceps performance 12 months after surgery.

RESULTS

Significant between-limb differences in each measure of quadriceps performance were identified (peak torque involved: 1.37 [0.71] Nm × kg-1; uninvolved: 1.87 [0.74] Nm × kg-1; RTD involved: 4.16 [2.75] Nm × kg-1 × s-1; uninvolved: 6.10 [3.02] Nm × kg-1 × × -1; and single-leg step-downs involved: 12.6 [5.0]; uninvolved: 21.7 [14.8]). Female biological sex, external fixation, and kinesiophobia at 12 months were associated with reduced after-surgery quadriceps performance outcomes.

CONCLUSION

Quadriceps performance is impaired 12 months after surgical repair of a lower extremity fracture, particularly in female participants, in cases requiring external fixation, and in those with higher kinesiophobia 12 months after surgery.

IMPACT

Because long-term quadriceps weakness negatively impacts functional mobility, targeted strengthening should be emphasized after surgical repair of lower extremity fracture.

Influence of quality of reduction using radiological criteria on kinematics and kinetics in ankle fractures with unstable syndesmotic injury

BACKGROUND

In ankle fractures with syndesmotic injury, the anatomic reduction of the ankle mortise is crucial for preventing osteoarthritis. Yet, no studies have analysed the effect of surgical reduction after unstable ankle fractures on patients' active functional outcome.

METHODS

The Intraoperative 3D imaging data of patients surgically treated between 2012 and 2019 for ankle fracture with concomitant syndesmotic injury were reviewed. 58 patients were allocated to two groups depending on whether the criteria for radiologically optimal reduction were met (39 patients) or not (19 patients). Criteria for optimal reduction were composed of objectively measured and subjectively rated data. After undertaking the Olerud/Molander ankle score, a gait analysis and several active function tests using 3D motion capture were performed in order to evaluate kinetic and kinematic differences between both groups.

FINDINGS

Patients showed deficits of range of motion and balance parameters on the injured ankle, however, there were no significant differences between both groups.

INTERPRETATION

Although, the data did not show that radiological reduction criteria have a statistically significant effect on active functional outcome after a mean follow up time of 5.7 years, tendencies for a better outcome of patients that met the criteria could be seen. It also must be taken into consideration that results are limited by case number and allocation ratio, which made a sub-analysis of the separate reduction criteria unfeasible.

Measuring Recovery and Understanding Long-Term Deficits in Balance, Ankle Mobility and Hip Strength in People after an Open Reduction and Internal Fixation of Bimalleolar Fracture and Their Impact on Functionality: A 12-Month Longitudinal Study

To analyze how balance and other physical capacities evolved after surgery in patients with a bimalleolar fracture and how these capacities and clinical variables (immobilization or unloading time) contribute to restoring patients’ functionality, 22 patients and 10 healthy people (HC) were assessed for static and dynamic balance (Y-Balance test, YBT), dorsiflexion ankle mobility (ADFROM) and hip strength at 6 and 12 months after surgery. Patients’ functional status was assessed through the Olerud Molander Ankle Score (OMAS) and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Twenty-one patients with ankle fractures who completed the study showed a worse static and dynamic balance at 6 months. The YBT in the anterior direction (YBTA) revealed balance deficits in the operated limb at 12 months compared to the non-operated limb (−5.6%) and the HC (−6.7%). They also showed a decreased ADFROM compared to the non-operated limb (−7.4°) and the HC (−11°). In addition, medium-term (6 months) deficits in abductor strength hip but no hip strength deficits were found at 12 months after surgery. Relative weight analyses showed that ADFROM and hip strength explained 35–63% of the YBTA variance and AOFAS/OMAS scores. Balance, hip strength and ADFROM seem to be reliable indexes for assessing the functional status of these patients. These results could help to understand the relationship between these physical capacities and the patients’ perceived functional status.

Effectiveness of Custom Foot Insoles to Decrease Plantar Pressure: A Cross-over Randomized Trial Study

Background: Harderness insoles decrease plantar pressure and reduce the foot injury incidence in sport. The purpose of our study was to analyze the plantar pressure variation in moto riders after riding in a real speed circuit with a custom foot 52⁰ Shore EVA insole. Methods: A crossover randomized trial study was performed (consent no. #050520165316). Riders were assessed by an expert motorsport senior podiatry. The participants’ mean age was 35 ± 3.29. Participants completed a 20 min training riding with their own motorcycle in a real speed circuit. Plantar pressures were registered with a baropodometric platform evaluating an Ethyl Vinyl Acetate custom foot insole (CFI) manufactured with 3 mm thickness and 52° Shore A hardness. The Plantar pressures were registered before riding, after riding without EVA insole, and after riding with EVA insole. Results: Total Plantar pressures in right and left foot, and total surface area decrease after riding with EVA insoles. Conclusion: The use of an EVA insole with 52⁰ shore A hardness riding on a motorcycle in speed circuit decreased the total plantar pressures and surface areas values.

Muscle synergies for the control of single-limb stance with and without visual information in young individuals

Purpose

Single-limb stance is a demanding postural task featuring a high number of daily living and sporting activities. Thus, it is widely used for training and rehabilitation, as well as for balance assessment. Muscle activations around single joints have been previously described, however, it is not known which are the muscle synergies used to control posture and how they change between conditions of normal and lack of visual information.

Methods

Twenty-two healthy young participants were asked to perform a 30 s single-limb stance task in open-eyes and closed-eyes condition while standing on a force platform with the dominant limb. Muscle synergies were extracted from the electromyographical recordings of 13 muscles of the lower limb, hip, and back. The optimal number of synergies, together with the average recruitment level and balance control strategies were analyzed and compared between the open- and the closed-eyes condition.

Results

Four major muscle synergies, two ankle-dominant synergies, one knee-dominant synergy, and one hip/back-dominant synergy were found. No differences between open- and closed-eyes conditions were found for the recruitment level, except for the hip/back synergy, which significantly decreased (p = 0.02) in the closed-eyes compared to the open-eyes condition. A significant increase (p = 0.03) of the ankle balance strategy was found in the closed-eyes compared to the open-eyes condition.

Conclusion

In healthy young individuals, single-limb stance is featured by four major synergies, both in open- and closed-eyes condition. Future studies should investigate muscle synergies in participants with other age groups, as well as pathological conditions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-021-00392-z.

Impact of Bone Fracture on Muscle Strength and Physical Performance-Narrative Review

PURPOSE OF REVIEW

Low muscle strength and poor physical performance are associated with high risk of fracture. Many studies assessed clinical and functional outcomes of fractures. Fewer studies analyzed the impact of fractures on muscle strength and physical performance.

RECENT FINDINGS

Vertebral fractures (especially multiple and severe ones) are associated with back pain, back-related disability, lower grip strength, lower strength of lower limbs, lower gait speed, and poor balance. Patients with hip fracture have slower gait and lower quadriceps strength. Non-vertebral fractures were associated with lower strength of the muscles adjacent to the fracture site (e.g., grip strength in the case of distal radius fracture, knee extensors in the case of patellar fracture) and poor physical function dependent on the muscles adjacent to the fracture site (e.g., limited range of motion of the shoulder in the case of humerus fracture, gait disturbances in the case of the ankle fracture). Individuals with a fracture experience a substantial deterioration of muscle strength and physical performance which exceeds that related to aging and is focused on the period close to the fracture occurrence. After fracture, muscle strength increased and physical performance improved. The rate of normalization depended partly on the therapeutic approach and on the rehabilitation program. A subgroup of patients, mainly the elderly, never returns to the pre-fracture level of physical performance. The permanent decline of physical function after fracture may be related to the limitation of movements due to pain, low physical activity, poor health before the fracture, and reduced efficacy of retraining after immobilization.

Effects of Tai Chi Chuan and Brisk Walking Exercise on Balance Ability in Elderly Women: A Randomized Controlled Trial

This study aims to investigate the effects of Tai Chi Chuan (TCC) and brisk walking (BW) on balance and training duration for the two exercises to significantly improve balance. A total of 48 elderly women were randomly divided into three groups. The TCC and BW groups completed a 60-min intervention training program with five sessions weekly for 16 weeks. Single-leg standing balance was tested every 4 weeks. Results showed that all the variables with eyes open improved on the eighth week (p < .05) in the TCC group and on the 12th week (p < .01) in the BW group. All variables with eyes closed improved on the 12th week (p < .01) in the TCC group and on the 16th week (p < .05) in the BW group. The results showed that 12 and 16 weeks of TCC and BW, respectively were essential to improve balance with eyes closed among the women aged 60-70 years.

Gait analysis related to functional outcome in patients operated for ankle fractures

Ankle fractures are among the most common lower limb fractures. Associations between postoperative radiographic results and clinical outcome have been found, but less is known about the relevant ankle biomechanics. This study analyzed ankle kinematics, radiographic findings, and patient-reported outcome measures (PROM) in patients treated for ankle fractures. The hypothesis was that patients after ankle fracture surgery had less flexion/extension in the ankle compared to healthy subjects and that fracture severity had significant influence on kinematics and patient satisfaction. Thirty-three patients (n = 33 feet) operated for ankle fractures were recruited. Ankle kinematics were analyzed using the Oxford Foot model, and results were compared with an age-matched healthy control group (11 patients, 20 feet). In addition, patients were divided by fracture (severity) classification and kinematic results were correlated with PROM and radiographic findings. Patients treated for ankle fracture showed lower walking speed (p < 0.001) when asked to walk in preferred normal speed. When compared at equal speed, significantly less range of motion (ROM) between the hindfoot and tibia in the sagittal plane (flexion/extension) during loading and push-off phases (p = 0.003 and p < 0.001) was found in patients after ankle fractures compared to healthy subjects. Lowest ROM and poorest PROM results were found for patients with trimalleolar ankle fractures. There was a significant correlation between ROM (flexion/extension) during the push-off phase and SF-36 physical functioning (r²  = 0.403, p = 0.027) and SF-36 general health (r²  = 0.473, p = 0.008). Fracture severity was significantly correlated with flexion/extension ROM in the ankle during both loading and push-off phases (r²  = -0.382, p = 0.005, and r²  = -0.568, p < 0.001) and was also significantly correlated with PROM. This study found that patients with ankle fractures had significantly altered ankle kinematics compared to healthy subjects. The poorest results were found among patients with trimalleolar fractures. Weak to strong significant correlations were found between fracture severity, ankle kinematics, and PROM. © 2019 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society. J Orthop Res 37:1658-1666, 2019.

Short-term Effects of Manual Therapy in Patients After Surgical Fixation of Ankle and/or Hindfoot Fracture: A Randomized Clinical Trial

BACKGROUND

Patients with surgical fixation of ankle and/or hindfoot fractures often experience decreased range of motion and loss of function following surgery and postsurgical immobilization, yet there is minimal evidence to guide care for these patients.

OBJECTIVES

To assess whether manual therapy may provide short-term improvements in range of motion, muscle stiffness, gait, and balance in patients who undergo operative fixation of an ankle and/or hindfoot fracture.

METHODS

In this multisite, double-blind randomized clinical trial, 72 consecutive patients who underwent open reduction internal fixation of an ankle and/or hindfoot fracture and were receiving physical therapy treatment of exercise and gait training were randomized to receive either impairment-based manual therapy (manual therapy group) or a sham manual therapy treatment of light soft tissue mobilization and proximal tibiofibular joint mobilizations (control group). Participants in both groups received 3 treatment sessions over 7 to 10 days, and outcomes were assessed immediately post intervention. Outcomes included ankle joint range of motion, muscle stiffness, gait characteristics, and balance measures. Group-by-time effects were compared using linear mixed modeling.

RESULTS

There were no significant differences between the manual therapy and control groups for range of motion, gait, or balance outcomes. There was a significant difference from baseline to the final follow-up in resting gastrocnemius muscle stiffness between the manual therapy and control groups (-47.9 N/m; 95% confidence interval: -86.1, -9.8; P = .01). There was no change in muscle stiffness for the manual therapy group between baseline and final follow-up, whereas muscle stiffness increased in the control group by 6.4%.

CONCLUSION

A brief course of manual therapy consisting of 3 treatment sessions over 7 to 10 days did not lead to better short-term improvement than the application of sham manual therapy for most clinical outcomes in patients after ankle and/or hindfoot fracture who were already being treated with exercise and gait training. Our results, however, suggest that manual therapy might decrease aberrant resting muscle stiffness after ankle and/or hindfoot surgical fixation.

LEVEL OF EVIDENCE

Therapy, level 2. J Orthop Sports Phys Ther 2019;49(5):310-319. Epub 13 Feb 2019. doi:10.2519/jospt.2019.8864.

Detraining effects of regular Tai Chi exercise on postural control ability in older women: A randomized controlled trial

BACKGROUND/OBJECTIVE

This study aimed to investigate the training and detraining effects of Tai Chi (TC) on postural control ability in single leg stance (SLS) by conducting a single-blind randomized controlled trial.

METHOD

Forty-eight older women were randomly divided into the TC, brisk walking (BW), and control(C) groups by using computer-generated program. The participants completed a 16-week intervention training and 8-week detraining program. Postural control ability in SLS was tested at the baseline, 16 t h, 20 t h, and 24 t h weeks. The primary outcomes included single-leg stance time (Time) and secondary outcomes included maximal displacement of the center of pressure (COP) in the anterior-posterior (AP) direction (D-ap), maximal displacement of the COP in the medial-lateral (ML) direction (D-ml), total length of the COP trajectories (Lng), and 95% confidence ellipse area of the COP movements (area), mean AP total excursion velocities (V-ap), and mean ML total excursion velocities (V-ml).

RESULTS

Significant within-group difference compared with the baseline and between-groups difference compared with control group were found at 16 t h, 20 t h, and 24 t h weeks in the TC group and at the 16 t h and 20 t h weeks in the BW group in all the primary and secondary outcomes. Most of secondary outcomes including Lng, D-ml, V-ml, Area increased significantly at the 24 t h week compared with that at the 16 t h week in BW group.

CONCLUSIONS

TC was effective in improving postural control ability and maintaining intervention gains, and was recommended as an appropriate exercise to prevent falls in the older adults.

The Immediate Effects of Different Types of Ankle Support Introduced 6 Weeks After Surgical Internal Fixation for Ankle Fracture on Gait and Pain: A Randomized Crossover Trial

STUDY DESIGN

Randomized 3-treatment, 3-period crossover trial.

BACKGROUND

There is variation in clinical practice regarding the type of ankle support used to aid recovery after ankle fracture internal fixation surgery.

OBJECTIVE

To determine the immediate effects of different ankle supports commonly issued to patients 6 weeks after surgery.

METHODS

Participants were 18 adults, 6 weeks after internal fixation for transsyndesmotic/infrasyndesmotic fracture, in a major trauma center in the UK. Interventions were a stirrup brace and walker boot compared with Tubigrip. Outcomes were (1) step-length and single-limb support time asymmetry (percentage comparing injured and uninjured limbs), (2) step width, (3) gait velocity, and (4) pain during walking (visual analog scale, 0-100).

RESULTS

Participants (mean ± SD age, 47 ± 14 years) included 8 women and 10 men, 6 weeks after surgical internal fixation for ankle fracture. Single-limb support time asymmetry reduced by 3% (95% confidence interval [CI]: 0%, 6%; P = .02) in the stirrup brace and by 5% (95% CI: 2%, 7%; P = .001) in the walker boot compared with Tubigrip. Step width was 1.2 cm (95% CI: 0.6, 1.7; P<.001) wider in the walker boot than in Tubigrip. Self-reported pain was lower in the walker boot (5/100) and in the stirrup brace (13/100) compared to the Tubigrip (18/100, P = .03). No significant differences were found in the effects of the supports on step-length asymmetry between the walker boot or stirrup brace and Tubigrip.

CONCLUSION

At 6 weeks after surgical internal fixation for ankle fracture, pain and single-limb support time asymmetry over a short distance and for a short-term walk were immediately reduced with the use of a walker boot use and, to a lesser extent, a stirrup-brace compared to Tubigrip. Step width also widened in a walker boot, which may confer some additional gait stability. These results apply to immediate effects, so studies with longer-term follow-up are now indicated. The trial was registered at http://www.isrctn.com/ (ISRCTN84536917). Level of Evidence Therapy, level 2b.

Wii balance board exercise improves balance and lower limb muscle strength of overweight young adults

[Purpose] The potential health benefits of the Nintendo Wii balance board exercise have been widely investigated. However, no study has been conducted to examine the benefits of Wii exercise for overweight young adults. The aim of this study was to investigate the effect of exercise performed on a Nintendo Wii balance board on the balance and lower limb muscle strength in overweight young adults. [Subjects and Methods] Within-subject repeated measures analysis was used. Sixteen young adults (aged 21.87±1.13 years, body mass index 24.15 ± 0.50 kg/m²) were recruited. All subjects performed an exercise program on a Wii balance board for 8 weeks (30 min/session, twice a week for 8 weeks). A NeuroCom Balance Master and a hand-held dynamometer were used to measure balance performance and lower limb muscle strength. [Results] According to the comparison of pre- and post-intervention measurements, the Wii balance board exercise program significantly improved the limit of stability parameters. There was also a significant increase in strength of four lower-limb muscle groups: the hip flexor, knee flexor, ankle dorsiflexor and ankle plantarflexor. [Conclusion] These findings suggest that a Wii balance board exercise program can be used to improve the balance and lower limb muscle strength of overweight young adults.

Early to mid-term results of fixed-bearing total ankle arthroplasty with a modular intramedullary tibial component

BACKGROUND

There has been a continuing increase in the use of total ankle arthroplasty for the treatment of end-stage ankle arthritis. Our aim was to determine the clinical, radiographic, and functional outcomes of total ankle arthroplasties done with a prosthesis with a modular intramedullary stem and intramedullary referencing to align the tibia.

METHODS

A consecutive series of patients who underwent total ankle arthroplasty with the INBONE Total Ankle Replacement from June 2007 to December 2010 were enrolled in this study. Pain and patient-reported function were assessed with use of a visual analog scale (VAS) for pain, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, the Short Musculoskeletal Function Assessment (SMFA), and the Short Form-36 (SF-36) Health Survey. Objective function was measured with assessment of walking speed, the Timed Up and Go (TUG) test, the Sit-to-Stand (STS) test, and the Four Square Step Test (4SST). Standardized weight-bearing radiographs obtained preoperatively and after total ankle arthroplasty were evaluated. We analyzed clinical, functional, and radiographic measurements with a series of repeated-measures analyses of variance (ANOVAs) with post-hoc testing to assess differences between preoperative, one-year postoperative, and most recent follow-up data. On the basis of the number of statistical comparisons, a Bonferroni correction was completed (alpha < 0.003).

RESULTS

We identified 194 primary INBONE total ankle arthroplasties with a mean duration of clinical follow-up of 3.7 years (range, 2.2 to 5.5 years). Patients demonstrated a significant improvement (p < 0.003) in VAS pain, AOFAS, SMFA, and SF-36 scores at the time of final follow-up, compared with preoperative values, and in walking speed, STS time, TUG time, and 4SST time at two years postoperatively, compared with preoperatively. The mean coronal tibiotalar angle for varus and valgus ankles significantly improved postoperatively and was maintained until the time of final follow-up. The prevalence of unstable subsidence leading to impending failure was 5%, and the prevalence of revision was 6%.

CONCLUSIONS

Patients who underwent total ankle arthroplasty with the INBONE Total Ankle Replacement demonstrated significant improvement in radiographic, functional, and patient-reported outcome scores at a mean of 3.7 years postoperatively. The overall implant survival rate was 89%.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Ankle Injury Management (AIM): design of a pragmatic multi-centre equivalence randomised controlled trial comparing Close Contact Casting (CCC) to Open surgical Reduction and Internal Fixation (ORIF) in the treatment of unstable ankle fractures in patients over 60 years

BACKGROUND

Ankle fractures account for 9% of all fractures with a quarter of these occurring in adults over 60 years. The short term disability and long-term consequences of this injury can be considerable. Current opinion favours open reduction and internal fixation (ORIF) over non-operative treatment (fracture manipulation and the application of a standard moulded cast) for older people. Both techniques are associated with complications but the limited published research indicates higher complication rates of fracture malunion (poor position at healing) with casting. The aim of this study is to compare ORIF with a modification of existing casting techniques, Close Contact Casting (CCC). We propose that CCC may offer an equivalent functional outcome to ORIF and avoid the risks associated with surgery.

METHODS/DESIGN

This study is a pragmatic multi-centre equivalence randomised controlled trial. 620 participants will be randomised to receive ORIF or CCC after sustaining an isolated displaced unstable ankle fracture. Participants will be recruited from a minimum of 20 National Health Service (NHS) acute hospitals throughout England and Wales. Participants will be aged over 60 years and be ambulatory prior to injury. Follow-up will be at six weeks and six months after randomisation. The primary outcome is the Olerud & Molander Ankle Score, a functional patient reported outcome measure, at 6 months. Follow-up will also include assessments of mobility, ankle range of movement, health related quality of life and complications. The six-month follow-up will be conducted face-to-face by an assessor blinded to the allocated intervention. A parallel economic evaluation will consider both a health service and a broader societal perspective including the individual and their family. In order to explore patient experience of their treatment and recovery, a purposive sample of 40 patients will also be interviewed using a semi-structured interview schedule between 6-10 weeks post treatment.

DISCUSSION

This multicentre study was open to recruitment July 2010 and recruitment is due to be completed in December 2013.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN04180738.

Effects of peripheral injury in athletes with long-term-exercise participation in modern pentathlons

This study was conducted to verify the effect of the ankle injury of athletes who attended the modern pentathlon for a long-term basis on ankle muscle’s strength and proprioceptive sensory function. For this, 10 athletes of the modern pentathlon, with experience of having damaged one side of their ankles within 6 months, and 10 healthy male college students, who have similar personal characteristics, such as height, age, and weight and have no experience of participating in regular sports for 3 or more times a week. The experimental subject was divided into 3 groups in all. After the flexor power of the plantar and dorsal side and the muscle strength of the varus and valgus for an ankle were measured by the Biodex System III at an angular velocity of 60°/sec and 120°/sec, it was documented as the maximum couple of force per body weight. Also, specified receptive senses were measured by the Biodex System III using the stop button to find the position (angle) of the joint. As a result of the conclusive research, participation in modern pentathlons for a long-term basis has caused an increase in valgus muscle strength and flexor power of the plantar side of the ankle when compared to general college students. Sports-related injury of the ankle was also found to result into the weakening of the flexor power on the plantar side and valgus muscle strength and a decrease of the proprioceptive sensory function.

J. Leonard Goldner Award 2011: changes in pain, function, and gait mechanics two years following total ankle arthroplasty performed with two modern fixed-bearing prostheses

BACKGROUND

Total ankle replacement (TAR) continues to grow as an alternative to arthrodesis for patients who suffer from end-stage ankle arthritis. The purpose of this study was to examine changes in gait mechanics from before surgery to 1 and 2 years after surgery in patients who received a fixed-bearing TAR.

METHODS

Fifty-one patients with a primary fixed-bearing TAR and no complications requiring further surgery were identified from a database and enrolled in this non-randomized study. Subjects were examined preoperatively, and at 1 and 2 years postoperatively. Three-dimensional joint mechanics and ground reaction forces (GRF) were collected during level walking. The Four Square Step Test, Timed Up and Go (TUG), VAS, and the AOFAS-Hindfoot score were assessed for each subject at each time point.

RESULTS

TUG, VAS and AOFAS-Hindfoot score along with all measured kinetic parameters demonstrated significant improvements across all of the time points (p < 0.05). Four Square Step Test time was significantly improved between the preoperative and 2-year postoperative time point (p < 0.05). Measured ankle dorsiflexion angles did not demonstrate significant change between any time points.

CONCLUSIONS

All of the observed changes suggest improved or maintained functioning in patients who received a TAR with the greatest improvement occurring within the first year. Sagittal plane ankle range of motion and dorsiflexion angle at heel strike were unchanged across all of the time points. The results of this study indicate that patients with end-stage osteoarthritis demonstrate improvements in pain and gait up to 2 years following surgery while maintaining ankle range of motion.

Dimensionality of measures for severe unilateral ankle arthritis

OBJECTIVE

To analyze the dimensionality of 2 self-report outcome measures (Foot/Ankle Disability Index [FADI] and Short-Form [SF]-36), 3 biomechanical measures (stance and step symmetry measures, gait speed, and step width), 2 physical-performance measures (timed get-up and go [TUG] and 4-square step test [4SST]), and 1 clinician-report outcome measure (American Orthopaedic Foot and Ankle Society [AOFAS] Hindfoot Scale) in a patient population with unilateral ankle arthritis. These measures captured the following functions: mobility and speed, pain and its relationship to function, social integration, and symmetry and efficiency of gait.

DESIGN

Case series design.

SETTING

Biomechanical research laboratory adjacent to a busy orthopedic clinical practice.

PATIENTS

Seventy-nine consecutive patients with unilateral traumatic arthritis who were candidates for a total ankle replacement.

METHODS

An exploratory factor analysis with oblimin rotation was performed to determine the dimensions of the physical performance, biomechanical, self-report, and clinician-report measures.

MAIN OUTCOME MEASUREMENTS

Outcomes measures included the SF-36 and pertinent subscales, gait speed, the 4SST, the TUG, the FADI, the AOFAS Hindfoot Scale, and biomechanical measures of step width, step symmetry, and stance symmetry.

RESULTS

Four distinct dimensions were captured during factor analysis. Factor 1 included the TUG, gait speed, the 4SST, and step width; factor 2 included the FADI, the SF-36 bodily pain score, and the SF-36 physical function score; factor 3 included the biomechanical scores of stance symmetry ratio and the step symmetry ratio; and factor 4 included SF-36 social functioning and the AOFAS Hindfoot Scale.

CONCLUSIONS

Findings suggest that various outcome measures for the ankle capture different dimensions and should be considered when evaluating the presence of disability or long-term change in outcome.

The effects of multiaxial and uniaxial unstable surface balance training in college athletes

The purpose of this study was to compare the effects of 2 different types of unstable surface balance training (uniaxial on a rocker board [RB] and multiaxial on a dynadisc [DD]) on balance in division 1 collegiate athletes in sports that are at high risk for ankle sprains. Subjects (n = 36) consisted of male soccer players and female volleyball and soccer players who were equally and randomly assigned to 1 of 3 groups (CON, DD, and RB). Balance training consisting of balancing on 1 leg on either the RB or DD, while repeatedly catching a 1-kg ball was performed 3 times per week for 4 weeks. Balance was tested with the Star Excursion Balance Test (SEBT) before, halfway through, and at the completion of the balance training. Control (CON) subjects also were given the balance test but did not participate in the training. A 3-way repeated analysis of variance revealed that no group individually changed SEBT scores from pre (CON, 0.98 +/- 0.086; DD, 0.98 +/- 0.083; RB, 0.97 +/- 0.085) to post (CON, 1.00 +/- 0.090; DD, 1.01 +/- 0.088; RB, 1.02 +/- 0.068) after balance training. When the 2 treatment groups were combined (DD and RB), the p value decreased and came closer to significance (p = 0.136). When all 3 groups were combined, there was a significant difference in SEBT scores from pretraining (CON + DD + RB; 0.98 +/- 0.085) to posttraining (CON + DD + RB; 1.01 +/- 0.082), which likely indicates low statistical power. The increase in physical activity the subjects experienced during the return to in-season activity, may have contributed to the significant differences in SEBT scores over time but not between DD or RB training. Therefore, a threshold level of physical activity may exist that is necessary to maintain balance during the off-season.

Motor ability in children treated for idiopathic clubfoot. A controlled pilot study

Background

To study motor ability at seven years of age in children treated for idiopathic clubfoot and its relation to clubfoot laterality, foot status and the amount of surgery performed.

Methods

Twenty children (mean age 7.5 years, SD 3.2 months) from a consecutive birth cohort from our hospital catchments area (300.000 inhabitants from southern Sweden) were assessed with the Movement Assessment Battery for Children (MABC) and the Clubfoot Assessment Protocol (CAP).

Results

Compared to typically developing children an increased prevalence of motor impairment was found regarding both the total score for MABC (p < 0.05) and the subtest ABC-Ball skills (p < 0.05). No relationship was found between the child's actual foot status, laterality or the extent of foot surgery with the motor ability as measured with MABC. Only the CAP item "one-leg stand" correlated significantly with the MABC (rs = -0.53, p = 0.02).

Conclusions

Children with idiopathic clubfoot appear to have an increased risk of motor activity limitations and it is possible that other factors, independent of the clinical status, might be involved. The ability to keep balance on one leg may be a sufficient tool for determining which children in the orthopedic setting should be more thoroughly evaluated regarding their neuromotor functioning.