Range of motion training in brace vs. plaster immobilization after anterior cruciate ligament reconstruction: a prospective randomized comparison with a 2-year follow-up

The purpose of this prospective and randomized study was to compare rehabilitation with early range of motion (ROM) training vs immobilization following anterior cruciate ligament (ACL) reconstruction. Fifty patients, undergoing an ACL reconstruction with a bone-patellar tendon-bone graft, were postoperatively allocated randomly to either a plaster cast or a brace for 5 weeks. The brace group had ROM exercises from postoperative day 7. The commencement of ROM exercises was postponed 4 weeks for the plaster group compared to the brace group, but progressed subsequently with equal speed. There was no difference between the groups in the ROM of flexion or extension 20 weeks after the ACL reconstruction and later. Twenty-four months after surgery, the muscle strength deficit in the hamstring muscles (isokinetic measurements; percent difference, injured vs uninjured) was significantly larger in the brace group (mean +/- SD: 5.9 +/- 7.8%, P < 0.01) than in the plaster group (- 0.9 +/- 11.8%, NS) (brace vs plaster group, P < 0.05). Furthermore, there was also a tendency in the brace group to a larger strength deficit in the quadriceps muscle (brace: 11.1 +/- 13.2%, P < 0.001; plaster: 3.8 +/- 12.9%, NS) (brace vs plaster group, P= 0.07). There was no difference between the groups in the total sagittal knee laxity, as measured with an arthrometer, or in the subjective knee function or activity level (Lysholm score together with the Tegner activity level) between the groups. It is concluded that the postoperative treatment with early range of motion training after ACL reconstruction gave as good ROM, knee stability, subjective knee function and activity level as the treatment with immobilization. It is hypothesized that the larger strength deficit observed after rehabilitation with early range of motion training is secondary to the more intensive training and physical therapist involvement that was demanded in order to achieve full ROM following immobilization.     

老年桡骨远端骨折治疗方法的探讨

目的对比分析手法复位石膏外固定和掌侧斜"T"形钢板内固定治疗老年桡骨远端骨折的疗效。方法 2010年10月—2011年6月分别采用手法复位加石膏托外固定及切开复位"T"形锁定钢板内固定治疗老年桡骨远端骨折146例,采用Gartland等腕关节评分进行功能评定,比较两种不同治疗方法的疗效。结果所有患者均获得随访,随访时间6～15个月,平均11.3个月。X线显示骨折全部愈合。Gartland腕关节评分手法复位石膏外固定组优良率为72.2%,掌侧斜"T"形钢板内固定组优良率为87.8%,差异有统计学意义(P<0.01)。结论尽管钢板内固定的优良率较高,但除少数经关节面且有明显关节面移位,非手术治疗失败的老年桡骨远端骨折可采用手术治疗外,大多数老年桡骨远端骨折经手法复位石膏外固定非手术治疗即可取得较为满意的临床效果,手术的选择应慎重,应尊重患者的要求。     

30例严重Colles骨折非手术治疗疗效分析

目的 观察严重Colles骨折经非手术治疗后的恢复情况,分析影响其预后的因素。方法 回顾1994－1996年间30例严重Colles骨折经非手术治疗的患者,观察2年以后的疗效,采用改良McBride评分及改良Green和O‘Brien评分进行统计分析。结果 改良McBride评分结果为优的7例,良6例,差1例;改良Green和O‘Brien评分结果为优的7例,良13例,可6例,差4例。通过X^2检验及线性相关分析,发现解剖与功能之间有明确的关系,桡骨短缩的纠正程度对功能结果的影响具有非常显著性意义。结论 治疗严重Colles骨折,如果仅以手法复位、石膏固定,复位不易维持,患者的功能恢复情况难以令人满意。     

Morphology of immobilized skeletal muscle and the effects of a pre- and postimmobilization training program

The hind limbs of mice were immobilized with plaster cast for different periods of time, and the atrophy of the anterior tibial muscle was examined by measuring fiber cross sections. In a second series of experiments, mice were trained on a treadmill before and after immobilization. The most pronounced decrease in fiber diameters was observed during the 1st week; during prolonged immobilization, only a moderate atrophy occurred. Red fibers were found to be more susceptible to immobilization atrophy than white fibers. The ultrastructural observations extended to loss and fragmentation of myofibrils, mitochondria, and the sarcotubular system. Some fibers split and appeared to undergo segmental necrosis, which was followed by invasion of leucocytes into the muscle. Still while immobilized, the muscles exhibited a regenerative capacity; satellite cells differentiated to myoblasts, which fused to myotubes, being the precursors of new muscle fibers. This was already observed during the 1st week of immobilization. The effect of training after immobilization was documented by an increase of fiber diameters. The ultrastructural alterations, however, in these muscles were severe; it was concluded that a postimmobilization training has to be undertaken very carefully. When the muscles were trained before immobilization, the atrophy was almost negligible. A preimmobilization training can probably prevent the muscle from developing severe atrophy.     

Tendon lengthening repair and early mobilization in treatment of neglected bilateral simultaneous traumatic rupture of the quadriceps tendon

Bilateral simultaneous traumatic rupture of the quadriceps tendon is a rare injury that is most frequently seen in elderly patients with predisposing diseases such as gout, hyperparathyroidism and diabetes. Delay in diagnosis is not uncommon. One of the main problems in treatment is loss of motion, especially flexion, after surgical repair. We report a case that was diagnosed 5 months after the trauma and was treated by Scuderi's tendon lengthening technique. Range-of-motion exercises were started early without using the generally recommended 4-6 weeks of immobilization in plaster cylinder or knee brace. Five years of follow-up showed full range of motion in both knees with sound tendons. Stable fixation makes starting early motion and accelerated rehabilitation feasible and thus the most common complication, loss of motion, is prevented.     

Treatment of complete rupture of the lateral ligaments of the ankle: a randomized clinical trial comparing cast immobilization with functional treatment

This study compared the therapeutic efficacy between cast immobilization and functional treatment of grade III ruptures of the lateral ankle ligaments. Subjects ( n=121) had closed physeal cartilage, age under 35 years, grade III rupture without previous or associated injuries, and practiced regular sports. Patients were randomized into an immobilization group (21 days plaster cast) or a functional one (15 days strapping plus early controlled mobilization). Symptoms (pain, swelling, stiffness, subjective instability), joint laxity, return to preinjury activity (time and level) and rate of reinjury were assessed 3, 6, and 12 months after sprain. Objective joint laxity was related to constitutional laxity, creating a new variable [talar tilt at injury - talar tilt at control]/contralateral talar tilt. The functional group showed significantly earlier and better return to physical activity, fewer symptoms at 3 and 6 months but no intergroup difference at 12 months. Functional treatment also showed better decrease in joint laxity. No intergroup differences were found in the reinjury rate. We conclude that functional treatment is safe, associated with a more rapid recovery, and particularly suitable in athletic populations.     

外固定器一期骨延长治疗火器伤骨折骨缺损的局部微循环变化

观察外固定器一期骨延长治疗火器伤骨折骨缺损的局部微循环变化。16只杂种犬,随机分2组。建立高速火器伤骨折缺损动物模型后,分别采用“外固定器一期骨延长”和传统的“早期石膏固定”两种方法治疗,在不同时间点对两组动物伤肢局部进行微循环测量。结果显示：（1）与普通开放性骨折不同,火器伤骨折局部血流量在3天内持续下降,以后逐步回升,至伤后6周恢复至接近正常的水平;（2）外固定器骨延长组和石膏组相比,骨折局部血流量恢复无明显差异。提示外固定器一期骨延长治疗火器伤骨折骨缺损对骨折局部血流量的恢复无不良影响。     

钩骨骨折（附7例报告）

本文报告7例钩骨骨折病例。该骨折在常规X线片上常不能显示，诊断依赖于特有的临床症状及腕管位片或特殊的腕斜位片。一旦确诊宜早期手术。     

Surgical treatment of extension contractures caused by war injuries to the knee

Immobilization with external fixation bridging the knee joint in extension is frequently used after sustaining a war injury to the region of the knee joint with femoral and tibial bone fractures. Immobilization of the knee with plaster splints is performed in the same position. This usually prolonged treatment results in extension contractures of the knee joint. From June 1991 until March 1994, 54 patients with extension contractures of the knee caused by war wounds were treated at the Department of Orthopedics, Zagreb University Hospital Center, in Zagreb, Croatia. Results of surgical treatment of 44 patients are presented. The operative procedure consisted of extensive intra- and extra-articular adhesiolysis of the knee. The control group included 30 patients with knee contractures caused by injuries sustained in car crashes or secondary to previous operative procedures. The mean duration of immobilization was 5 months and 6 days. The mean preoperative knee motion amplitude ranged from 5 degrees in extension to 38 degrees in flexion. The mean postoperative knee motion was 98 degrees (range, 2 to 110 degrees). Treatment results did not depend on either duration of preoperative immobilization of the knee or previous infection in the region of injury. Previous knee joint bridging with an external fixator had no impact on the results of extension contracture treatment. Adequate intra- and extra-articular adhesiolysis with appropriate long-term postoperative rehabilitation is essential for the success of the operative treatment for knee joint contracture.     

跟骨骨折伴外踝骨折12例临床分析

目的：对12例跟骨骨折伴外踝骨折病例进行临床回顾性分析.方法：收集2009-01～2011-03本院跟骨骨折伴外踝骨折患者12例,所有患者均为高处坠落伤.所有患者跟骨骨折行外侧切口钛板螺钉内固定术;对外踝骨折,4例采用空心钉外固定,其余8例采用术后石膏外固定.术后对患者进行随访.结果：12例患者随访时间12～18月,患者对手术治疗效果评价：非常满意10例,满意2例,无出现外踝疼痛,肿胀等现象.结论：单纯跟骨骨折伴外踝骨折是临床少见骨折类型,虽然经过积极治疗后,能获得满意效果,但临床医师应重视此类型骨折存在.     

经皮加压螺钉内固定术治疗腕舟骨腰部骨折的效果

 目的 探讨掌侧入路经皮加压螺钉内固定治疗军事训练致急性腕舟骨腰部骨折的效果。方法 回顾性分析2017-09至2020-06武警贵州总队医院收治的15例急性腕舟骨腰部骨折患者,采用微创经皮掌侧入路螺钉内固定治疗,予注射器针头定位成功后置入导针,沿导针完成螺钉置入。术后石膏制动2周,分阶段功能锻炼。15例术后随访平均(18.13±8.68)个月,采用修订版Mayo腕关节功能评分系统评估疗效,疼痛视觉模拟评分评定患者疼痛情况,末次随访记录双腕关节屈伸、尺桡偏的关节活动度及握力。结果 15例手术均顺利完成,术中出血(2.50±1.02) ml;手术时间(44.73±5.67) min;术中、术后均无并发症发生。术后骨折顺利愈合,平均愈合时间(10.33±2.29) 周,Mayo腕关节功能评分优14例,良1例。疼痛视觉模拟评分0分12例,4分1例,1分2例。末次随访记录双腕屈伸、尺桡偏的关节活动度及握力进行对比,差异无统计学意义。结论 经皮加压螺钉内固定术治疗急性腕舟骨腰部骨折,方法简单、有效,手术时间短,避免了长时间石膏制动产生的关节僵硬。     

闭合复位穿针治疗小儿肱骨髁上骨折25例分析

目的探讨小儿肱骨髁上骨折治疗方法的选择及闭合复位内固定并发症的预防。方法回顾性分析25例明显移位的小儿肱骨髁上骨折采用在C臂下闭合复位交叉克氏针治疗的临床效果。结果随访时间3—24个月,平均9个月。骨折均在6周内愈合,关节功能无限制,无明显肘内外翻畸形。1例术后尺神经支配区感觉减退,拔除克氏针后消失,无1例感染。结论移位明显的肱骨髁上骨折,复位容易,但固定及维持复位困难,手法复位石膏或夹板外固定虽是首选治疗方法,但石膏或夹板固定不牢固,易出现松动甚至可造成血管及神经损伤,而切开复位更易进一步造成软组织创伤,组织粘连,最终导致关节僵直功能障碍。本组C臂下闭合复位交叉克氏针治疗移位明显的肱骨髁上骨折避免了上述缺点,而且方法简单。     

Nonunions of stress fractures of the tibia

Stress fractures of the tibia commonly occur in the proximal metaphysis and heal readily with rest. Fractures of the middle third of the tibia, on the other hand, are uncommon. We encountered six stress fractures of the middle third of the tibia over a 5 year period. None of these fractures healed with simple immobilization. One was treated with electromagnetic stimulation and failed to unite 2 years after presentation. One patient underwent a biopsy of the lesion without bone grafting and it had not healed when he was last seen. One patient sustained two acute complete fractures, and the stress fracture finally healed after the second acute fracture was openly reduced and internally fixed. The other three lesions were excised and grafted because of failure to unite. They all healed promptly. Stress fractures of the middle third of the tibia are unusual lesions. However, care must be taken in treating them. The patient must protect the extremity until the fracture has completely healed. Surgical excision and bone grafting of the lesion may be required if the fracture does not heal with plaster immobilization.     

Subtalar Dislocation in a Basketball Player

In brief: Easily mistaken for an ankle fracture during the initial examination, medial subtalar dislocation—also known as ‘basketball foot’—requires plaster immobilization for no more than 3 weeks. To extend immobilization beyond this time can lead to reduced range of motion in the subtalar joint, making it difficult for the athlete to resume sports activities. Encouraging toe motion while the patient is still in the cast prevents tendon adhesions. In this case report, the author discusses the importance of short-term immobilization and early rehabilitation for a 21-year-old basketball player recovering from medial subtalar dislocation.     

术中备皮及弹力绷带在封闭负压引流中的应用

目的探讨应用术中备皮及弹力绷带预防封闭式负压引流(VSD)术后密封不严而失去效能的作用。方法 2008—2010年对31例VSD覆盖创面患者用术中半透膜粘贴范围备皮,术后用弹力绷带进行加压包扎,并根据有无骨折使用骨牵引或石膏固定肢体制动,统计贴膜粘失效时间,与既往随机抽取72例失效时间进行比较。结果 VSD半透膜覆盖区采用术中备皮及应用弹力绷带后,早期可明显延缓VSD的失效时间,促进组织愈合。结论 VSD覆盖采用术中备皮及应用弹力绷带方法,能延缓贴膜黏性胶失效时间,提高VSD使用疗效。     

Metabolic activity in early tendon repair can be enhanced by intermittent pneumatic compression

Since Achilles tendon healing is protracted, more knowledge of metabolites known to meet the demands for biosynthesis and proliferation is needed. We hypothesized that essential metabolites, glutamate, glucose, lactate, pyruvate and glycerol, are present and upregulated in healing Achilles tendons. We moreover hypothesized that adjuvant intermittent pneumatic compression (IPC), which increases blood flow, upregulates metabolite concentrations. Twenty patients with acute Achilles tendon rupture were recruited, operated, and included. The control group, 15 patients, received plaster cast immobilization, while five patients received adjuvant foot IPC beneath the plaster cast. At 2 weeks postoperatively, microdialysis of the healing and contralateral intact Achilles tendons was followed by quantification of metabolites. Healing compared to intact tendons of the controls exhibited significantly increased concentrations (mM) of glutamate (60 ± 14 vs 20 ± 11), lactate (1.15 ± 0.60 vs 0.64 ± 0.35), and pyruvate (81 ± 29 vs 35 ± 25, μM). Healing tendons of the IPC vs control group displayed higher levels of glutamate (84 ± 15 vs 62 ± 16) and glucose (3.44 ± 0.62 vs 2.62 ± 0.72); (P < 0.05) and trends toward higher concentrations of pyruvate, lactate, and glycerol (P < 0.10). The present study demonstrates that early Achilles tendon repair entails and upregulates local essential metabolites. This metabolic response can, during tendon healing with plaster cast immobilization, be promoted by adjuvant IPC.     

Ruptured fibular ankle ligament: plaster or Pliton brace?

A prospective randomised study was performed in order to compare plaster cast with Pliton-80 cast brace with a mobile plastic shoe insert in the treatment of ruptured fibular ankle ligaments. The two treatment groups consisted of 65 patients in each and all were participating in the follow-up sixth months after the accident. There were no statistically significant differences in the overall results between the two treatment groups. Because 1) the mobile Pliton-80 bandage subjectively is more acceptable to the patients and -2) the disability time in the Pliton-80 group was considerably shorter than in the plaster group--it was concluded that the mobile Pliton-80 bandage can be recommended as the treatment of ruptures of the fibular ankle ligaments.     

Early mobilization versus immobilization after ankle ligament stabilization

Functional outcome, stability at radiographic investigation and ankle joint torque after anatomical reconstruction of the lateral ankle ligaments were evaluated in patients with early postoperative mobilization versus those with cast immobilization. Thirty patients with chronic lateral ligament instability of the ankle underwent anatomical reconstruction of the ligaments. Postoperatively the patients were randomly allocated to two groups: Group A (n=15) were immobilized in a below-knee plaster for 6 weeks and Group B (n=15) underwent early controlled range of motion training using an Air-Cast ankle brace. The functional results were evaluated using a scoring scale and objective results using standardized stress radiographs. Also eccentric and concentric muscle torque at 60 degrees/s was measured in plantar flexion and dorsiflexion, respectively. The functional results were satisfactory in 12/15 ankles in Group A and 14/15 in Group B (n.s.). All the patients with satisfactory results regained normal range of motion. Patients with unsatisfactory results had either residual pain or recurrent instability. In Group B, the strength measurements revealed significantly higher peak torque values after three months in plantar flexion at 60 degrees/s. Six months postoperatively, the torque values did not differ significantly between the groups. Also, there was no group difference in the laxity of the ankle joint, including both anterior talar translation test and talar tilt test, at the two-year follow-up. One patient had a superficial wound infection. We conclude that after the reconstruction of chronic lateral ligament instability of the ankle the functional and stability results were equally good with early postoperative mobilization and 6-week immobilization. However, using early mobilization plantar flexion strength was regained earlier than with cast immobilization, without any risk of short- or medium-term complications, such as increased ankle laxity. We recommend early mobilization after anatomical reconstruction of the lateral ankle ligaments.     

The closed wedge varus supracondylar osteotomy

Osteotomy of the distal femur is an established technique for treating of a valgus deformity caused by lateralcompartment osteoarthritis of the knee or ligamentous instability. We describe our technique of a closed wedge osteotomy through a medial approach with fixation by an AO 90° hip blade plate avoiding plaster cast immobilization and allowing early joint movements.     

Long-term results after surgical management of partial Achilles tendon ruptures

Although Achilles tendon injuries are common overuse injuries in sports, the exact incidence is unknown, primarily as a result of varying definitions and diagnoses of the underlying pathological changes. Despite numerous studies of treatment of the Achilles tendon injuries, the longterm results are not well known. The results after surgical treatment of chronic partial Achilles tendon ruptures in 64 patients with a follow-up of 6 (1.5–11) years were evaluated in a retrospective study. The ruptures were divided into three groups: (I) proximal (more than 3 cm above the calcaneus), (II) distal and (III) combined (proximal and distal). All patients underwent an operation involving the excision of the devitalized tendon tissue and, in groups (II) and (III), also the excision of the deep Achilles bursa and removal of the dorsal corner of the calcaneus. The functional results were satisfactory in 43 (67%) patients and unsatisfactory in 21 (33%). The results were better in patients with proximal ruptures than in patients with either distal or combined ruptures. Males experienced better results than females. Post-operative immobilization in a plaster cast had no significant influence on the final result. Nine (14%) patients with either a distal or a combined rupture were re-operated on and in seven of them the final result was satisfactory. The conclusion of this study is that partial Achilles tendon ruptures are often difficult to treat and only two out of three patients can be expected to obtain satisfactory results after surgical treatment.