Hexcelite versus plaster of Paris: a controlled trial of the below-knee walking cast

Revolution in orthopedic immobilization materials: A comprehensive review

Immobilization material has slowly revolutionized since 3000 BCE from traditional plaster to modern day synthetic casting tape, including other sustainable immobilization material. This revolution is driven by the search for superior casting material that possesses excellent mechanical and load-bearing properties, non-toxicity, excellent healing rates, patient satisfaction and eco friendliness. Even though the new materials have been evolved, the traditional plaster still remains a material of choice owing to its excellent skin conformability, low cost and availability. This paper aims to present a comprehensive review on the technique of immobilization, existing orthopedic immobilization (casting and splinting) materials and complications associated with immobilization (mainly casting) which aimed to assist the medical practitioners and researchers in casting material improvements and selection. Nine immobilization materials are comprehensively discussed for their desirable properties, drawbacks and the required improvements to the composition, along with the most common cast complications ranging from superficial pressure sores to compartment syndrome and Deep Vein Thrombosis. . This paper identifies that among the existing material, plaster casts are still highly used due to their cost benefit and the ability to fit patients into full body casts, while synthetic material is too rigid and has a higher probability of causing complications such as compartment syndrome and deep vein thrombosis. Patients show a higher preference in using synthetic casts for short term and body extremity casting as they are comparatively more comfortable. New materials such as Woodcast shows good promise but their mechanical characteristics and comfort are yet to be critically analyzed. However, there exists an imminent requirement to upgrade existing material as well as to introduce novel promising sustainable material for long term immobilization.

Rehabilitation for ankle fractures in adults

BACKGROUND

Rehabilitation after ankle fracture can begin soon after the fracture has been treated, either surgically or non-surgically, by the use of different types of immobilisation that allow early commencement of weight-bearing or exercise. Alternatively, rehabilitation, including the use of physical or manual therapies, may start following the period of immobilisation. This is an update of a Cochrane review first published in 2008.

OBJECTIVES

To assess the effects of rehabilitation interventions following conservative or surgical treatment of ankle fractures in adults.

SEARCH METHODS

We searched the Specialised Registers of the Cochrane Bone, Joint and Muscle Trauma Group and the Cochrane Rehabilitation and Related Therapies Field, CENTRAL via The Cochrane Library (2011 Issue 7), MEDLINE via PubMed, EMBASE, CINAHL, PEDro, AMED, SPORTDiscus and clinical trials registers up to July 2011. In addition, we searched reference lists of included studies and relevant systematic reviews.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials with adults undergoing any interventions for rehabilitation after ankle fracture were considered. The primary outcome was activity limitation. Secondary outcomes included quality of life, patient satisfaction, impairments and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, assessed risk of bias and extracted data. Risk ratios and 95% confidence intervals (95% CIs) were calculated for dichotomous variables, and mean differences or standardised mean differences and 95% CIs were calculated for continuous variables. End of treatment and end of follow-up data were presented separately. For end of follow-up data, short term follow-up was defined as up to three months after randomisation, and long-term follow-up as greater than six months after randomisation. Meta-analysis was performed where appropriate.

MAIN RESULTS

Thirty-eight studies with a total of 1896 participants were included. Only one study was judged at low risk of bias. Eight studies were judged at high risk of selection bias because of lack of allocation concealment and over half the of the studies were at high risk of selective reporting bias.Three small studies investigated rehabilitation interventions during the immobilisation period after conservative orthopaedic management. There was limited evidence from two studies (106 participants in total) of short-term benefit of using an air-stirrup versus an orthosis or a walking cast. One study (12 participants) found 12 weeks of hypnosis did not reduce activity or improve other outcomes.Thirty studies investigated rehabilitation interventions during the immobilisation period after surgical fixation. In 10 studies, the use of a removable type of immobilisation combined with exercise was compared with cast immobilisation alone. Using a removable type of immobilisation to enable controlled exercise significantly reduced activity limitation in five of the eight studies reporting this outcome, reduced pain (number of participants with pain at the long term follow-up: 10/35 versus 25/34; risk ratio (RR) 0.39, 95% confidence interval (CI) 0.22 to 0.68; 2 studies) and improved ankle dorsiflexion range of motion. However, it also led to a higher rate of mainly minor adverse events (49/201 versus 20/197; RR 2.30, 95% CI 1.49 to 3.56; 7 studies).During the immobilisation period after surgical fixation, commencing weight-bearing made a small improvement in ankle dorsiflexion range of motion (mean difference in the difference in range of motion compared with the non-fractured side at the long term follow-up 6.17%, 95% CI 0.14 to 12.20; 2 studies). Evidence from one small but potentially biased study (60 participants) showed that neurostimulation, an electrotherapy modality, may be beneficial in the short-term. There was little and inconclusive evidence on what type of support or immobilisation was the best. One study found no immobilisation improved ankle dorsiflexion and plantarflexion range of motion compared with cast immobilisation, but another showed using a backslab improved ankle dorsiflexion range of motion compared with using a bandage.Five studies investigated different rehabilitation interventions following the immobilisation period after either conservative or surgical orthopaedic management. There was no evidence of effect for stretching or manual therapy in addition to exercise, or exercise compared with usual care. One small study (14 participants) at a high risk of bias found reduced ankle swelling after non-thermal compared with thermal pulsed shortwave diathermy.

AUTHORS' CONCLUSIONS

There is limited evidence supporting early commencement of weight-bearing and the use of a removable type of immobilisation to allow exercise during the immobilisation period after surgical fixation. Because of the potential increased risk of adverse events, the patient's ability to comply with the use of a removable type of immobilisation to enable controlled exercise is essential. There is little evidence for rehabilitation interventions during the immobilisation period after conservative orthopaedic management and no evidence for stretching, manual therapy or exercise compared to usual care following the immobilisation period. Small, single studies showed that some electrotherapy modalities may be beneficial. More clinical trials that are well-designed and adequately-powered are required to strengthen current evidence.

Efficacy of patient information concerning casts applied post-fracture

INTRODUCTION

Serious complications can result when casts are used for bone immobilization following fracture. Adequate patient information regarding cast care and possible complications is vital for prevention. This study examines the effectiveness of verbal and written patient information regarding cast safety.

METHODS

Patients (n= 109; age ≥18 years) from three Western Australian teaching hospitals were interviewed using a custom-designed questionnaire. Patients' understanding of cast care and possible complications were tested by recall of seven categories of information, notably: pain, swelling, cast care, itching, neural signs, vascular signs/symptoms, exercise/rest. A follow-up phone call (3-8 weeks after initial interview) was conducted to elicit complications and determine information recall.

RESULTS

Written information was received by 62% of patients; however, overall, only 35% claimed to have read the information provided. Of these, the highest recall was in four of seven information categories. A high proportion of those given only verbal information had poor recall (≤2 categories, defined a priori). In contrast, patients who also received written information had better recall (three or more categories, defined a priori, P= 0.031). Four of the 109 patients developed complications attributable to the cast (three had pressure ulcers and one had a deep vein thrombosis).

CONCLUSION

Patient recall of information concerning cast care and possible complications was no more than 60%. The provision of written information was associated with a significantly higher awareness of possible complications. The results indicate that for fracture care, the delivery and use of information protocols can be greatly improved.

WITHDRAWN: Interventions for treating acute Achilles tendon ruptures

BACKGROUND

There is lack of consensus on the best management of the acute Achilles tendon (TA) rupture. Treatment can be broadly classified into operative (open or percutaneous) and non-operative (cast immobilisation or functional bracing). Post-operative splintage can be with a rigid cast (above or below the knee) or a more mobile functional brace.

OBJECTIVES

To identify and summarise the evidence from randomised controlled trials of the effectiveness of different interventions in the treatment of acute Achilles tendon ruptures.

SEARCH STRATEGY

We searched multiple databases including the Cochrane Musculoskeletal Injuries Group specialised register (to September 2003), reference lists of articles and contacted trialists. Keywords included Achilles Tendon, Rupture, and Tendon Injuries.

SELECTION CRITERIA

All randomised and quasi-randomised trials comparing different treatment regimens for acute Achilles tendon ruptures.

DATA COLLECTION AND ANALYSIS

Three reviewers extracted data and independently assessed trial quality by use of a ten-item scale.

MAIN RESULTS

Fourteen trials involving 891 patients were included. Several of the studies had poor methodology and inadequate reporting of outcomes.Open operative treatment compared with non-operative treatment (4 trials, 356 patients) was associated with a lower risk of rerupture (relative risk (RR) 0.27, 95% confidence interval (CI) 0.11 to 0.64), but a higher risk of other complications including infection, adhesions and disturbed skin sensibility (RR 10.60, 95%CI 4.82 to 23.28).Percutaneous repair compared with open operative repair (2 studies, 94 patients) was associated with a shorter operation duration, and lower risk of infection (RR 10.52, 95% CI 1.37 to 80.52). These figures should be interpreted with caution because of the small numbers involved.Patients splinted with a functional brace rather than a cast post-operatively (5 studies, 273 patients) tended to have a shorter in-patient stay, less time off work and a quicker return to sporting activities. There was also a lower complication rate (excluding rerupture) in the functional brace group (RR 1.88 95%CI 1.27 to 2.76).Because of the small number of patients involved no definitive conclusions could be made regarding different operative techniques (1 study, 51 patients), different non-operative treatment regimes (2 studies, 90 patients), and different forms of post-operative cast immobilisation (1 study, 40 patients).

AUTHORS' CONCLUSIONS

Open operative treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared to non-operative treatment, but produces a significantly higher risk of other complications, including wound infection. The latter may be reduced by performing surgery percutaneously. Post-operative splintage in a functional brace appears to reduce hospital stay, time off work and sports, and may lower the overall complication rate.

Rehabilitation for ankle fractures in adults

BACKGROUND

Rehabilitation after ankle fracture can begin soon after the fracture has been treated by the use of different types of immobilisation which allow early commencement of weight-bearing or exercise. Alternatively, rehabilitation may start following the period of immobilisation, with physical or manual therapies.

OBJECTIVES

To compare the effectiveness of rehabilitation interventions following ankle fracture in adults.

SEARCH STRATEGY

We searched two Specialised Registers of The Cochrane Collaboration, electronic databases (including MEDLINE, EMBASE and CINAHL), reference lists of included studies and relevant systematic reviews, and clinical trials registers to September 2007.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials with adults undergoing any interventions for rehabilitation after ankle fracture were considered. The primary outcome was activity limitation. Secondary outcomes included impairments and adverse events.

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened search results, assessed methodological quality, and extracted data. Relative risk and 95% confidence intervals (95% CI) were calculated for dichotomous variables, and weighted or standardised mean difference and 95% CI were calculated for continuous variables. A meta-analysis was performed where appropriate.

MAIN RESULTS

Thirty-one studies were included. Clinical and statistical heterogeneity prevented meta-analyses in most instances. After surgical fixation, commencing exercise in a removable brace or splint significantly improved activity limitation, pain and ankle range of motion, but also led to a higher rate of adverse events. Early commencement of weight-bearing during the immobilisation period improved ankle range of motion after surgical fixation. Where it was possible to avoid ankle range of motion after surgical fixation, the use of no immobilisation compared to cast immobilisation also improved ankle range of motion. After the immobilisation period, manual therapy was beneficial in increasing ankle range of motion. There was no evidence of effect for electrotherapy, hypnosis, or stretching.

AUTHORS' CONCLUSIONS

There is limited evidence supporting the use of a removable type of immobilisation and exercise during the immobilisation period, early commencement of weight-bearing during the immobilisation period, and no immobilisation after surgical fixation of ankle fracture. There is also limited evidence for manual therapy after the immobilisation period. Because of the potential increased risk, the patient's ability to comply with the use of a removable type of immobilisation and exercise is essential. More clinical trials that are well-designed and adequately-powered are required to strengthen current evidence.

Interventions for treating acute Achilles tendon ruptures

BACKGROUND

There is lack of consensus on the best management of the acute Achilles tendon (TA) rupture. Treatment can be broadly classified into operative (open or percutaneous) and non-operative (cast immobilisation or functional bracing). Post-operative splintage can be with a rigid cast (above or below the knee) or a more mobile functional brace.

OBJECTIVES

To identify and summarise the evidence from randomised controlled trials of the effectiveness of different interventions in the treatment of acute Achilles tendon ruptures.

SEARCH STRATEGY

We searched multiple databases including the Cochrane Musculoskeletal Injuries Group specialised register (to September 2003), reference lists of articles and contacted trialists. Keywords included Achilles Tendon, Rupture, and Tendon Injuries.

SELECTION CRITERIA

All randomised and quasi-randomised trials comparing different treatment regimens for acute Achilles tendon ruptures.

DATA COLLECTION AND ANALYSIS

Three reviewers extracted data and independently assessed trial quality by use of a ten-item scale.

MAIN RESULTS

Fourteen trials involving 891 patients were included. Several of the studies had poor methodology and inadequate reporting of outcomes. Open operative treatment compared with non-operative treatment (4 trials, 356 patients) was associated with a lower risk of rerupture (relative risk (RR) 0.27, 95% confidence interval (CI) 0.11 to 0.64), but a higher risk of other complications including infection, adhesions and disturbed skin sensibility (RR 10.60, 95%CI 4.82 to 23.28). Percutaneous repair compared with open operative repair (2 studies, 94 patients) was associated with a shorter operation duration, and lower risk of infection (RR 10.52, 95% CI 1.37 to 80.52). These figures should be interpreted with caution because of the small numbers involved. Patients splinted with a functional brace rather than a cast post-operatively (5 studies, 273 patients) tended to have a shorter in-patient stay, less time off work and a quicker return to sporting activities. There was also a lower complication rate (excluding rerupture) in the functional brace group (RR 1.88 95%CI 1.27 to 2.76). Because of the small number of patients involved no definitive conclusions could be made regarding different operative techniques (1 study, 51 patients), different non-operative treatment regimes (2 studies, 90 patients), and different forms of post-operative cast immobilisation (1 study, 40 patients).

REVIEWERS' CONCLUSIONS

Open operative treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared to non-operative treatment, but produces a significantly higher risk of other complications, including wound infection. The latter may be reduced by performing surgery percutaneously. Post-operative splintage in a functional brace appears to reduce hospital stay, time off work and sports, and may lower the overall complication rate.

A clinical evaluation of plaster-of-Paris and eight synthetic fracture splinting materials

A number of new synthetic orthopaedic splinting materials, all claiming substantial advantages over the traditional plaster-of-Paris, have been introduced in recent years. However, although their properties have been extensively measured in the laboratory, little has been documented concerning their performance in clinical use. This study was therefore initiated as a comparative evaluation of the clinical characteristics and ease of use of these relatively expensive materials in the fabrication of below-knee weight-bearing casts. The study encompassed nine materials--seven based on water-activated polyurethanes, one thermoplastic and plaster-of-Paris, and involved a total of 203 patients. It was concluded that plaster-of-Paris should be used for all routine splinting applications, but that in cases in which cast weight, cast bulk, or the time to bearing weight is important, a synthetic material, chosen principally on the basis of cost, is indicated.