A performance test protocol and scoring scale for the evaluation of ankle injuries

Post-traumatic missing medial malleolus: case report with a one-year follow-up

INTRODUCTION AND IMPORTANCE

Ankle fractures result from a wide variety of mechanisms the biomechanics of this articulation make any fracture altering the contact of the articulation surface lead to increased stresses and an inevitable evolution to tibiotalar arthritis.

CASE PRESENTATION

We report the case of a 56-year-old patient admitted for open fracture dislocation of the ankle with a missing medial malleolus. He was treated by external fixation k-wiring and periosteal repair of the deltoid ligament. The one-year follow-up shows a good functional outcome with the patient's satisfaction.

CLINICAL DISCUSSION

In ankle fractures, some authors report no need for fixation of the medial malleolus. Furthermore, the absence of the medial malleolus is not necessarily accompanied by instability of the ankle; however, it inevitably leads to ankle osteoarthritis.

CONCLUSION

Our patient admitted for a bimalleolar fracture with missing medial malleolus, as described in the literature, had a favorable evolution with a functional score that was judged fair.

Acute Ankle Sprain in Elite Athletes: How to Get Them Back to the Game?

Despite the high frequency of ankle sprains, the ideal management is controversial, and a significant percentage of patients sustaining an ankle sprain never fully recover. There is strong evidence that residual disability of ankle joint injury is often caused by an inadequate rehabilitation and training program and early return to sports. Therefore, the athlete should start their criteria-based rehabilitation and gradually progress through the programmed activities, including cryotherapy, edema relief, optimal weight-bearing management, range of motion exercises for ankle dorsiflexion improvement, triceps surae stretching, isometric exercises and peroneus muscles strengthening, balance and proprioception training, and bracing/taping.

Current Concept Review: State of Acute Lateral Ankle Injury Classification Systems

Acute lateral ankle sprain (ALAS) is one of the most frequent musculoskeletal injuries, with a great impact on health and socioeconomic factors. There are few consensuses on this subject and multiple therapeutic options that are difficult to compare due to the lack of a universally adopted classification system. The objective of this study is to is to report the actual knowledge on how ALAS are classified and reported and not to make any therapeutic recommendation. A comprehensive literature review of the literature was carried out through a search in the MEDLINE, Cochrane Library and Google Scholar databases, with identification of articles that describe ways to classify lateral ankle sprains or with relevant content for their classification. Twenty-five different classification systems were identified. The majority of articles referring to ALAS use an unspecific classification. Most classification systems divide sprains into 3 degrees. The most used parameters are the anatomy of the injury, clinical parameters, functional loss and the presence of instability. No articles were found to verify the validity of the systems used, namely regarding their association with therapeutic proposals or prognostic predictions. Based on the available evidence, recommendations cannot be made regarding the most appropriate classification system. The considerable heterogeneity of the existing literature makes it difficult to compare studies and to optimize the treatment and follow-up of these injuries. Future research in this area is necessary to define a practical and rigorous system that can be used universally.

Virtual planning of the anterolateral thigh free flap for heel reconstruction

PURPOSE

three dimensional (3-D) virtual planning is an example of computer assisted surgery that improved management of composite tissue defects. However, converting the 3-D construct into two dimensional format is challenging. The purpose of this study was to assess 3-D virtual planning of complex heel defects for better optimized reconstruction.

PATIENTS AND METHODS

a prospective analysis of 10 patients [9 male and 1 female; mean age = 27.9 years] with post-traumatic heel defects was performed. Heel defects comprised types II (three patients) or III (seven patients) according to Hidalgo and Shaw and were managed using anterolateral thigh (ALT) free flap adopting 3-D virtual planning of the actual defect which was converted into a silicone two dimensional mold. The mean definitive size of the defects was 63.4 cm³ . Functional, aesthetic, and sensory evaluations of both donor and recipient sites were performed 1 year after surgery.

RESULTS

Six patients received thinned ALT (mean size = 139 cm³ ) while four patients received musculofasciocutaneous ALT flap (mean size = 199 cm³ ). One flap exhibited partial skin flap necrosis. Another flap was salvaged after re-exploration secondary to venous congestion. The mean follow-up was 20.2 months. The Maryland foot score showed 4 excellent, 5 good, and 1 fair cases. The mean American Orthopedic Foot and Ankle hind foot scoring was 76.3 (range: 69-86). All patients regained their walking capability.

CONCLUSIONS

3-D virtual planning of complex heel defects facilitates covering non-elliptical defects while harvesting a conventional elliptical flap with providing satisfactory functional outcomes and near-normal contour, volume, and sensibility.

Effectiveness of Mobilization of the Talus and Distal Fibula in the Management of Acute Lateral Ankle Sprain

OBJECTIVE

Distal fibular mobilization with movement (MWM), with and without a posterior gliding fibular tape, and anteroposterior mobilization of the talus (MOB) are widely used to treat acute lateral ankle sprains. The purpose of this study was to investigate the short-term and long-term relative effectiveness of these techniques.

METHODS

In this double-blind randomized controlled trial, 45 amateur soccer players with acute (<72 hours) lateral ankle sprain were randomly allocated to 6 sessions (3/wk within the first 2 weeks) of either MWM, MWM with tape (MWMtape), or MOB. All participants also received general advice, transcutaneous electrical nerve stimulation, edema draining massage, and a program of proprioception exercises. Participant ratings of function on the Foot and Ankle Ability Measure and Patient Global Impression of Improvement Scale were the primary outcomes measured over 52 weeks. Secondary outcomes were ankle pain, pressure pain threshold, range of motion, volume, and strength.

RESULTS

MWM and MWMtape were equally effective and participants demonstrated greater function on the Foot and Ankle Ability Measure at 12 and 52 weeks when compared with those receiving MOB; however, the latter demonstrated superior function at 2 weeks. No differences between groups were observed for Patient Global Impression of Improvement Scale or any of the secondary outcomes.

CONCLUSION

There are limited differences in the short term among techniques, with the exception of better sport function with MOB. Over the longer term, the distal fibular MWM is most effective to achieve activities of daily living and sport function when added to usual physical therapy care. The addition of a posterior gliding fibular tape provides no additional benefit.

IMPACT

Distal fibular mobilization with movement may be the most appropriate choice of treatment for acute lateral ankle sprain to achieve long-term activities of daily living and sport function. In the short term, anteroposterior mobilization of the talus offers greater improvement in sport function. The use of fibular tape provides no added benefit as an adjunct to a treatment that includes distal fibular mobilization with movement.

Acute ankle sprain in athletes: Clinical aspects and algorithmic approach

Acute ankle sprain is the most common lower limb injury in athletes and accounts for 16%-40% of all sports-related injuries. It is especially common in basketball, American football, and soccer. The majority of sprains affect the lateral ligaments, particularly the anterior talofibular ligament. Despite its high prevalence, a high proportion of patients experience persistent residual symptoms and injury recurrence. A detailed history and proper physical examination are diagnostic cornerstones. Imaging is not indicated for the majority of ankle sprain cases and should be requested according to the Ottawa ankle rules. Several interventions have been recommended in the management of acute ankle sprains including rest, ice, compression, and elevation, analgesic and anti-inflammatory medications, bracing and immobilization, early weight-bearing and walking aids, foot orthoses, manual therapy, exercise therapy, electrophysical modalities and surgery (only in selected refractory cases). Among these interventions, exercise and bracing have been recommended with a higher level of evidence and should be incorporated in the rehabilitation process. An exercise program should be comprehensive and progressive including the range of motion, stretching, strengthening, neuromuscular, proprioceptive, and sport-specific exercises. Decision-making regarding return to the sport in athletes may be challenging and a sports physician should determine this based on the self-reported variables, manual tests for stability, and functional performance testing. There are some common myths and mistakes in the management of ankle sprains, which all clinicians should be aware of and avoid. These include excessive imaging, unwarranted non-weight-bearing, unjustified immobilization, delay in functional movements, and inadequate rehabilitation. The application of an evidence-based algorithmic approach considering the individual characteristics is helpful and should be recommended.

Functional evaluation of triceps surae during heel rise test: from EMG frequency analysis to machine learning approach

Soleus muscle flap as coverage tissue is a possible surgical solution adopted to cover the wounds due to open fractures. Despite this procedure presents many clinical advantages, relatively poor information is available about the loss of functionality of triceps surae of the treated leg. In this study, a group of patients who underwent a soleus muscle flap surgical procedure has been analyzed through the heel rise test (HRT), in order to explore the triceps surae residual functionalities. A frequency band analysis was performed in order to assess whether the residual heads of triceps surae exhibit different characteristics with respect to both the non-treated lower limb and an age-matched control group. Then, an in-depth analysis based on a machine learning approach was proposed for discriminating between groups by generalizing across new unseen subjects. Experimental results showed the reliability of the proposed analyses for discriminating between-group at a specific time epoch and the high interpretability of the proposed machine learning algorithm allowed the temporal localization of the most discriminative frequency bands. Findings of this study highlighted that significant differences can be recognized in the myoelectric spectral characteristics between the treated and contralateral leg in patients who underwent soleus flap surgery. These experimental results may support the clinical decision-making for assessing triceps surae performance and for supporting the choice of treatment in plastic and reconstructive surgery. Graphical Abstract The Graphical abstract presents the scope of the proposed analysis of myoelectric signals of soleus and gastrocnemius muscles of patiens groups during Hell Rise Test, highlighting the applied methods and the obtained results.

Symptom and Disability Measurement by Common Foot and Ankle-Specific Outcome Rating Scales

BACKGROUND

Well-designed foot and ankle clinical outcomes research requires region-specific subjective outcome measures. Many foot and ankle-specific instruments are now available. Determining which instruments to choose is daunting. We present a patient survey to determine the most relevant questions pertaining to them.

METHODS

Sixteen foot and ankle-specific outcome instruments were chosen based on popularity, emphasizing valid, reliable, responsive scores. Subjective portions were consolidated and given to 109 patients with osteochondral lesion of the talus (OLT) (39), ankle instability (35), and ankle arthritis (35). Outcome instruments were measured according to 4 criteria: number of questions endorsed by 51%, number with high mean importance, number with low mean importance, and number with the highest-ranking frequency importance product. Instruments were then ranked based on relative score, with the highest scores indicating the instrument was the most useful for that sample.

RESULTS

The Foot and Ankle Outcome Score (FAOS) achieved the highest score in all 4 categories for OLT, followed by Foot and Ankle Ability Measure (FAAM) and American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Score. The FAOS achieved the highest score in all 4 categories for ankle instability, followed by FAAM and AAOS. For osteoarthritis, the FAOS achieved the highest relative score followed by FAAM and AAOS. The AOF, Ankle Osteoarthritis Score, and AAS are instruments commonly used that had lower relative scores.

CONCLUSION

The FAOS, FAAM, and AAOS Foot and Ankle Score contain several items important to patients with osteochondral lesions of the talus, ankle instability, and ankle osteoarthritis.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Return to Play After a Lateral Ligament Ankle Sprain

Purpose of Review

The purpose of this review is to describe the current evidence on the most common sports-related ankle injuries. Joint anatomy, epidemiology, clinical findings, diagnostic approach, and treatment are presented with a specific focus on the available evidence towards return to play.

Recent Findings

Recent findings show that ankle sprain is the most common injury in the world of sports. Bony fractures, cartilage defects, and syndesmotic lesions are frequently seen in association with the more severe type of ankle sprains.

Summary

In summary, the majority of the athletes’ ankle sprains are managed conservatively with excellent outcomes and full return to their pre-injury level of play. However, it is essential to differentiate the single ligament sprain from a more complex injury to the ankle joint. The evidence-based treatment and rehabilitation programmes are associated with a better prognosis and a faster time to return to sport participation.

Staged procedure protocol based on the four-column concept in the treatment of AO/OTA type 43-C3.3 pilon fractures

OBJECTIVE

We herein introduce a staged management protocol for AO/OTA type 43-C3.3 pilon fractures based on the four-column theory designed to protect the soft tissue.

METHODS

Twenty-three patients with 25 type C3.3 pilon fractures underwent a staged procedure with four-column osteosynthesis from April 2014 to December 2016. The first stage involved immediate calcaneal traction or external fixation to span the ankle joint. When the soft tissue swelling decreased, the posterolateral approach was used to restore the lateral column and initially fix the posterior column. After 10 to 12 days, the third stage involved treatment of the anterior and medial columns through the anterior approach. Charts and radiographs were reviewed, and the American Orthopaedic Foot and Ankle Society (AOFAS) evaluation system was used to evaluate the postoperative outcomes.

RESULTS

All fractures achieved union after a mean of 3.3 months (range, 2.0-5.7 months) after the third stage. A good or acceptable reduction rate was observed in 85.7% of the patients. Results from the AOFAS evaluation system indicated excellent or good postoperative ankle function in 81.0% of the patients.

CONCLUSION

This staged procedure protocol combined with the four-column theory is a feasible way to protect the soft tissue and reduce the fracture.

Effects of two proprioceptive training programs on ankle range of motion, pain, functional and balance performance in individuals with ankle sprain

BACKGROUND

Following ankle sprain, residual symptoms are often apparent, and proprioceptive training is a treatment approach. Evidence, however, is limited and the optimal program has to be identified.

OBJECTIVE

To investigate the effects of two post-acute supervised proprioceptive training programs in individuals with ankle sprain.

METHODS

Participants were recruited from a physiotherapy center for ankle sprain rehabilitation. In a pre-post treatment, blinded-assessor design, 22 individuals were randomly allocated to a balance or a proprioceptive neuromuscular facilitation (PNF) group. Both groups received 10 rehabilitation sessions, within a six-week period. Dorsiflexion range of motion (ROM), pain, functional and balance performance were assessed at baseline, at the end of training and eight weeks after training.

RESULTS

Follow-up data were provided for 20 individuals. Eight weeks after training, statistically significant (p< 0.017) improvements were found in dorsiflexion ROM and most functional performance measures for both balance and PNF groups. Eight weeks after training, significant (p< 0.017) improvements in the frontal plane balance test and pain were observed for the balance group.

CONCLUSIONS

Balance and PNF programs are recommended in clinical practice for improving ankle ROM and functional performance in individuals with sprain. Balance programs are also recommended for pain relief.

Large variation in use of patient-reported outcome measures: A survey of 188 foot and ankle surgeons

BACKGROUND

There is an increasing interest in the use of patient reported outcome measures (PROMs). However, there is a large variety of PROMs and a lack of consensus regarding preference for their use. Aim of this study is to determine how often PROMS are used for foot and ankle disorders, for what purpose PROMs are used, and what the preferences of the foot and ankle surgeons are, when choosing a PROM to use.

METHODS

Members of the Ankleplatform Study Group-Science of Variation Collaborative were invited to participate in this survey by email. The online survey consisted of six questions on the use and preferences regarding foot and ankle PROMs.

RESULTS

188 participants completed the questionnaire. Of the respondents 17% reported not to use PROMs, 72% stated to use PROMS for research, 39% routinely for patient care and 34% for registration or quality assessment. The respondents were familiar with 30 different outcome measures, of which 20 were PROMs. One of the excluded outcome measures, the AOFAS Hindfoot scale was most commonly reported as preferred outcome measure. FAOS and MOXFQ were the preferred PROMs, reported by 9.7% of the surgeons. Subsequently followed by the FFI (4.3%), the FAAM (3.7%) and the VAS-FA (3.7%).

CONCLUSIONS

A large majority of the foot and ankle surgeons uses PROMs. The AOFAS hindfoot scale is mentioned as the most preferred outcome measure, while in fact this is not a PROM. Of the twenty different PROMs mentioned in this study, most reported were the FAOS and MOXFQ both supported by only 9.7% of the surgeons. For proper comparison between patients in clinical practice and research, consensus is needed on which easy-to-use PROM with adequate clinimetric properties should be used. Therefore more evidence in the field of clinimetrics of foot and ankle outcome measures is needed.

Non-anatomical or direct anatomical repair of chronic lateral instability of the ankle: A systematic review of the literature after at least 10 years of follow-up

INTRODUCTION

A lateral ankle sprain is one of the most frequent reasons for consultation at the emergency trauma unit. Numerous surgical procedures have been described with long-term outcomes that differ.

HYPOTHESIS

The long-term results of anatomical repair of the anterior talofibular ligament (ATFL) and the calcaneofibular (CFL) ligament are better, with less secondary radiological osteoarthritis than non-anatomical repair.

MATERIALS AND METHODS

A review of the literature after a minimum follow-up of 10 years was performed to analyze the clinical and radiological results of direct anatomical repair (Broström, Duquennoy) and non-anatomical repair (Watson Jones, Evans, Castaing). Thirteen articles were selected.

RESULTS

Eight hundred and one ankles were evaluated after a mean follow-up of 15.3 years. The functional outcome was better after anatomical repair but with recurrent instability. Loss of range of motion and secondary osteoarthritis was more frequent after non-anatomical repair.

CONCLUSION

Anatomical repair of the lateral collateral ligament of the ankle resulted in a better functional outcome and less secondary osteoarthritis than non-anatomical repair.

STUDY DESIGN

Review of the literature; level of proof IV.

Predicting poor outcome from simple ankle injuries: a prospective cohort study

BACKGROUND

Sprained ankles are common and when there are no signs or evidence of a fracture, conventional management is conservative. At present, there are no clinical markers to identify those that may develop persisting instability and disability that would require rehabilitation or surgery.

OBJECTIVES

To investigate the nature and extent of soft tissue ankle injuries, and to consider whether the anatomical severity of injury can predict functional outcome.

METHODS

Patients attending a local Accident and Emergency Department in Oxford with an acute ankle injury with no clinical requirement for radiographs, or where radiographs were normal, were invited into the study. Within 5 days, patients underwent a diagnostic ultrasound examination, a cone beam CT study and a disability assessment. Ultrasound and physiotherapy assessments were repeated at 3 and 6 months.

RESULTS

100 patients were recruited and grouped based upon injuries. 58 had simple ankle injuries, 21 complex, 19 had significant fractures and 2 were excluded from further follow up analysis. There were no clinically significant differences in pain, disability or functional outcomes between the groups at all points of the study.

CONCLUSION

Medium to long term clinical outcomes were not solely determined by the severity of injury. Some patients with simple injuries were seen to have ongoing problems, whereas some with complex injuries recovered completely in a shorter period. Advances in knowledge: The severity of an ankle injury determined by radiological imaging does not necessarily dictate the severity of a patient's symptoms and the trajectory of their recovery.

Readability of Orthopaedic Patient-reported Outcome Measures: Is There a Fundamental Failure to Communicate?

BACKGROUND

Patient-reported outcome measures (PROMs) are increasingly used to quantify patients' perceptions of functional ability. The American Medical Association and NIH suggest patient materials be written at or below 6th to 8th grade reading levels, respectively, yet one recent study asserts that few PROMs comply with these recommendations, and suggests that the majority of PROMs are written at too high of a reading level for self-administered patient use. Notably, this study was limited in its use of only one readability algorithm, although there is no commonly accepted, standard readability algorithm for healthcare-related materials. Our study, using multiple readability equations and heeding equal weight to each, hopes to yield a broader, all-encompassing estimate of readability, thereby offering a more accurate assessment of the readability of orthopaedic PROMS.

QUESTIONS/PURPOSES

(1) What proportion of orthopaedic-related PROMs and orthopaedic-related portions of the NIH Patient Reported Outcomes Measurement Information System (PROMIS®) are written at or below the 6th and 8th grade levels? (2) Is there a correlation between the number of questions in the PROM and reading level? (3) Using systematic edits based on guidelines from the Centers for Medicare and Medicaid Services, what proportion of PROMs achieved American Medical Association and NIH-recommended reading levels?

METHODS

Eighty-six (86) independent, orthopaedic and general wellness PROMs, drawn from commonly referenced orthopaedic websites and prior studies, were chosen for analysis. Additionally, owing to their increasing use in orthopaedics, four relevant short forms, and 11 adult, physical health question banks from the PROMIS®, were included for analysis. All documents were analyzed for reading grade levels using 19 unique readability algorithms. Descriptive statistics were performed using SPSS Version 22.0.

RESULTS

The majority of the independent PROMs (64 of 86; 74%) were written at or below the 6th grade level, with 81 of 86 (94%) written at or below the 8th grade level. All item banks (11 of 11) and short forms (four of four) of the PROMIS® were written below the 6th grade reading level. The median reading grade level of the 86 independent PROMs was 5.0 (interquartile range [IQR], 4.6-6.1). The PROMIS® question banks had a median reading grade level of 4.1 (IQR, 3.5-4.8); the Adult Short Forms had a median reading grade level of 4.2 (IQR, 4.2-4.3) There was no correlation appreciated between the median reading grade level and the number of questions contained in a PROM (r = -0.081; p = 0.460). For PROMs above NIH-recommended levels, following edits, all (five of five) achieved NIH reading level goals and three (three of five) achieved American Medical Association goals. Editing of these PROMs improved readability by 4.3 median grade level (before, 8.9 [IQR, 8.4-9.1], after 4.6 [IQR, 4.6-6.4], difference of medians, 4.3; p = 0.008).

CONCLUSIONS

Patient literacy has great influence on healthcare outcomes, and readability is an important consideration in all patient-directed written materials. Our study found that more than 70% of PROMs commonly used in orthopaedics, and all orthopaedic-related portions of the PROMIS® are written at or below the most stringent recommendations (≤ 6th grade reading level), and more than 90% of independent PROMs and all PROMIS® materials are written at or below an 8th grade level. Additionally, the use of the Centers for Medicare and Medicaid Services guidelines for editing high reading level PROMs yields satisfactory results.

CLINICAL RELEVANCE

Fears of widely incomprehensible PROMs may be unfounded. Future research to identify the most appropriate readability algorithm for use in the healthcare sector, and revalidation of PROMs after readability-improving edits is warranted.

Treatment and outcome prognosis of patients with high-energy transsyndesmotic ankle fracture dislocation-the "Logsplitter" injury

Background

This study aimed to retrospectively review the clinical efficacy of open reduction and internal fixation (ORIF) for treatment of high-energy transsyndesmotic ankle fracture dislocation—the “Logsplitter” injury.

Methods

Between December 2006 and December 2014, 41 patients (29 males and 12 females; mean age, 41.46 ± 13.42 years) with Logsplitter injury were treated by ORIF procedure. Patients were grouped as typical injury (mainly vertical axial stress) and untypical injury (mainly rotational stress) according to the injury mechanism and the degree of the talus wedged into the distal tibiofibular joint.

Results

After the follow-up of 32.48 ± 24.18 weeks, average American Orthopedic Foot and Ankle Society (AOFAS) score at final follow-up was 78.54 ± 10.66 and the excellent and good rate of 82.9%. Three patients in typical group developed nonunion, and other three cases had infection vs. none in untypical group (both P = 0.053). Burwell-Charnely scoring system revealed anatomic reduction of fracture was achieved in 22 cases, fair reduction in 16 cases, and poor in only 3 cases. Patients in untypical group had better fracture reduction (P = 0.015) and lower incidence rate of posttraumatic ankle arthritis (P = 0.042) than typical cases as well as the range of motion (P < 0.01).

Conclusions

The ORIF may be an optimal approach to treat Logsplitter injuries. Patients with untypical injury had better fracture reduction, range of motion, and low incidence rate of posttraumatic ankle arthritis than those typical ones, and the postoperative outcome was affected by the injury and treatment characteristics.

Arthroscopic debridement of the ankle for mild to moderate osteoarthritis: a midterm follow-up study in former professional soccer players

Background

The aim of this study is to report the clinical and functional outcomes following arthroscopic management of anterior impingement, grade III–IV cartilage lesions, and mild to moderate osteoarthritis of the ankle in former soccer players.

Methods

The study included 15 former male professional soccer players with mild to moderate degenerative changes of the ankle who had undergone arthroscopic debridement and management of secondary injuries of the ankle. Preoperatively and at the last follow-up, at an average of 7.4 years, the American Orthopaedic Foot and Ankle Society (AOFAS) and the Kaikkonen scales and visual analogue scale (VAS) assessment were administered to all patients. Ankle osteoarthritis was assessed from weightbearing anteroposterior and lateral radiographs of both ankles.

Results and discussion

At the last follow-up, the average AOFAS score had increased significantly from 48 (range, 29–69) to 86 (range, 63–94) (P < 0.0001), with good to excellent scores in 11 patients (74 %). The average Kaikkonen preoperative score of 43 (range, 28–70) had significantly improved to 85 (range, 61–95) (P < 0.0001), with good excellent scores in 11 patients (74 %). VAS values were also improved at the last follow-up. At the last appointment, only one (7 %) patient had abandoned altogether any sport, as he did not feel safe with his ankle and he felt too old to continue.

Conclusions

Anterior ankle arthroscopy for management of mild to moderate ankle arthritis is safe, effective, and low cost and allows former athletes to safely return to ordinary daily activities and recreational sport activities.

Are patient-reported outcome measures in orthopaedics easily read by patients?

BACKGROUND

Patient-reported outcome measures (PROMs) are commonly used by healthcare providers as means of assessing health-related quality of life and function at any given time. The complexity of PROMs can differ and when combined with varying degrees of adult literacy, error can be introduced if patients fail to understand questions. With an average adult literacy level of 11-year-old students in the United Kingdom, it is unclear to what degree PROMs can be read and understood by most patients (readability); to our knowledge, this has not been evaluated.

QUESTIONS/PURPOSES

We wished to determine the readability of commonly used PROMs in orthopaedic surgery, as assessed by a validated tool that measures the complexity of the language in these surveys.

METHODS

We performed a MEDLINE search to identify the most-commonly reported PROMs in orthopaedic research. One hundred twenty-one PROMs were identified and reviewed by 19 attending orthopaedic surgeons at our institution. Fifty-nine were selected as the most commonly used in our department. Of these, 52 (78%) were disease specific and included: 12 (20%) knee, 10 (17%) shoulder, seven (12%) spine, six (10%) hip, five (8%) foot and ankle, four (7%) elbow, three (5%) pelvis, three (5%) hand and wrist, and two (3%) lower limb. The remaining seven (12%) PROMs were general health questionnaires. The Flesch Reading Ease Score is a validated readability tool measuring average sentence length and syllables per word. It is expressed on a scale from 0 to 100 with higher scores indicating easier reading. We extracted the text from each PROM and inserted it in the same online Flesch Reading Ease Score calculator to generate a score.

RESULTS

The mean readability score was 55 (range, 0-93), corresponding to text best understood by 16- to 18-year-old students (11th-12th grades). Twenty-nine PROMs (49%) scored less than 60, classifying them as at least fairly difficult to read. Eight (14%) scored less than 30, best understood by university graduates. Only seven of 59 PROMs analyzed scored greater than 79, corresponding to text that can be understood by the average UK adult.

CONCLUSIONS

The majority of PROMs analyzed are written at a level that is incomprehensible to the average UK adult.

CLINICAL RELEVANCE

This issue needs to be addressed if we are to continue basing our research conclusions on outcome scores. The information obtained is useful for patients to understand their musculoskeletal health, governmental agencies allocating healthcare resources, provision of management guidelines, and as a link to other data sets, such as hospital episodes statistics. Accurate and reliable data can be obtained only if patients who complete these evaluations are able to read and understand the questions asked.

Early functional outcome of two different orthotic concepts in ankle sprains: a randomized controlled trial

INTRODUCTION

Purpose of the study was the evaluation of the early functional outcome of patients with an acute ankle sprain treated either with a semirigid, variable, phase-adapted modular ankle orthosis or an invariable orthotic reference device.

MATERIALS AND METHODS

Forty-seven patients with acute ankle sprain grade II or more were included. In addition, 77 healthy controls as a reference were investigated. The injured subjects were treated with one of the two devices by random for 6 weeks. Ankle scores (FAOS, AOFAS) were taken at baseline after injury, 1 and 3 months after injury. Functional performance tests (balance platform, zig zag run, shuttle run, vertical drop jump) were performed at 1 and 3 months after injury.

RESULTS

No significant score differences could be found between the two intervention groups except for achieving a preinjury activity level after 3 months only in the modular orthosis group. Postural functional performances (balance test) also showed no significant differences whereas the results of the agility tests revealed small but significant better results in the modular orthosis group in comparison to the invariable orthosis group. Cohen's effect sizes were high.

CONCLUSION

Differences between the two intervention groups were marginal and very small but significant and--regarding Cohen's effect sizes--effective. Especially relating to functional performance, this might be a careful indication that a more effective strategy for promoting a protected, rapid recovery to physical activity after ankle sprains might be achieved by applying a phase-adapted ankle orthosis. Especially in athletic patients, phase-adapted orthosis should be further investigated and considered to ensure fully protected ligament healing as well as to regain early functional recovery.

Return to play after an ankle sprain: guidelines for the podiatric physician

The ankle sprain is the most common injury in sport and has a high incidence of long-term disability. This disability may be partly due to early return to sport before ligament healing has been completed. The podiatric physician can follow sound guidelines for making a return-to-play decision for athletes suffering from an ankle sprain. The decision-making process requires the podiatric physician to monitor the rehabilitation process and then administer patient self-reported questionnaires as well as functional performance tests to assess the status of ankle function after injury.

Traumatic tibialis anterior tendon rupture: treatment with a two-stage silicone tube and an interposition hamstring tendons graft protocol

A novel technique for managing ruptured tibialis anterior tendon complicated by infection and tendon substance loss in a young adult is described. A two-stage reconstruction technique with a silicon tube and tendon autograft was performed. At first, after local control of the infection, scar excision and placement of a silicone tube was performed. Ten weeks later, ipsilateral hamstrings tendons were harvested and bridged the 7 cm tendon gap. Eighteen months later, the patient has excellent clinical and functional outcome.

Flap reconstruction for soft-tissue defects with exposed hardware following deep infection after internal fixation of ankle fractures

The aim of the present study was to determine the outcome for patients treated with flap reconstruction following deep ankle fracture infection with exposed hardware. Out of 3041 consecutive ankle fracture operations in 3030 patients from 2006 to 2011, we identified 56 patients requiring flap reconstruction following deep infection. Thirty-two of these patients could be examined at a follow-up visit. Olerud-Molander Ankle (OMA) score, 15D score, Numeric Rating Scale (NRS), and clinical examination were used to assess the outcome. A total of 58 flap reconstructions were performed in 56 patients with a mean age of 57 years (range 25–93 years) and mean follow-up time of 52 months. The most commonly used reconstruction was a distally based peroneus brevis muscle flap with a split-thickness skin graft. A microvascular free flap was required in only one patient. 22 (39%) patients required subsequent surgical interventions because of a flap-related complication. With flap reconstruction, hardware could eventually be salvaged in 53% of patients with a non-consolidated fracture. The mean OMA score was fair or poor in 53% of the patients, and only 56% had recovered their pre-injury level of function. Half of the patients had shoe wear limitations. The 15D score showed a significantly poorer health-related quality of life compared to an age-standardised sample of the general population. The mean pain NRS was 2.1 (range 0–6), and the mean satisfaction NRS was 6.6 (range 0–10). Our study showed that successful treatment of a soft-tissue defect with exposed hardware following ankle fracture infections can be achieved with local flaps. Despite eventual reconstructive success, complications are common. Patients perceive a poorer health-related quality of life, have shoe wear limitations, and only half of them achieve their pre-injury level of function.

Bracing versus casting in ankle fractures

Casting and splinting techniques for treating patients with fractures have been used for centuries. Functional bracing after ankle fracture has recently been utilized in an effort to avoid the atrophy and stiffness sometimes associated with casting; functional bracing allows for early mobilization of the ankle joint during recovery. Our review investigated the published literature comparing bracing with casting after ankle fracture. Studies examining both operatively and nonoperatively treated ankle fractures were included. There is minimal evidence supporting the use of functional bracing over cast immobilization to improve functional outcome, range of motion, swelling, or post-traumatic arthrosis after ankle fracture in the long term. The primary benefits of functional bracing are the potential to return to work earlier and bracing may facilitate activities of daily living, such as bathing and dressing. In addition, there may be a decreased patient risk of developing deep vein thrombosis due to immobilization. However, there is an increased risk of wound infection when using a brace after open reduction and internal fixation of an unstable ankle fracture. Functional bracing can be used for treating stable and postoperative ankle fractures in compliant patients to potentially expedite and facilitate the recovery process.

Acupuncture for treating acute ankle sprains in adults

BACKGROUND

An acute ankle sprain is a sudden-onset injury of one or more of the ankle ligaments. It is one of the most common musculoskeletal injuries in the general population as well as in athletes. In some countries, such as China and Korea, acupuncture is frequently used in the treatment of ankle sprains, either as a single treatment or a secondary intervention accompanied by standard medical treatment.

OBJECTIVES

To assess the effects (benefits and harms) of acupuncture for the treatment of ankle sprains in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (May 2013), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2013, Issue 4), MEDLINE (1948 to May week 2 2013), EMBASE (1980 to May week 2 2013), China National Knowledge Infrastructure databases (1994 to August week 4 2013), the Cumulative Index to Nursing and Allied Health Literature (1937 to May 2013), the Allied and Complementary Medicine Database (1985 to May 2013), Science Links Japan (1996 to August week 4 2013), several Korean medical databases (August week 4 2013), the World Health Organization International Clinical Trials Registry Platform (August week 4 2013), the bibliographic references of included trials and conference proceedings.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials involving adults with acute ankle sprains. We included all types of acupuncture practices, such as needle acupuncture, electroacupuncture, laser acupuncture, pharmacoacupuncture, non-penetrating acupuncture point stimulation (e.g. acupressure and magnets) and moxibustion. Acupuncture could be compared with control (no treatment or placebo) or another standard non-surgical intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the search results, assessed trial eligibility, assessed risk of bias and extracted data from the included trials. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences for continuous outcomes. We conducted meta-analyses using the fixed-effect method or, where appropriate, the random-effects method, and used 95% confidence intervals (CI) throughout.

MAIN RESULTS

We included a total of 20 heterogeneous studies (2012 participants with acute ankle sprains); three of which included more than one comparison. Seventeen trials were conducted in China. All of the studies had a high risk of bias due to lack of blinding. The results may also have been affected by selection bias, particularly as five studies were quasi-randomised controlled trials and 12 studies gave no information on their method of randomisation. Of our three prespecified primary outcomes, only cure rate was reported by the majority of studies. No study reported on patient-reported assessment of function and only one reported on adverse events (in which three participants receiving a control intervention experienced skin problems from over-the-counter Chinese herbal patches). The other 19 studies did not record or report on adverse events. We assessed the quality of evidence for cure rates as very low for all comparisons, which means we are very uncertain about the reliability of any of the estimates.The single study comparing acupuncture treatment with no treatment found acupuncture to be more effective with regard to cure rate at five days (31/31 versus 1/30; RR 20.34, 95% CI 4.27 to 96.68). Acupuncture plus another standard treatment versus that standard treatment alone was tested in eight studies; with cure rate data available for seven. Most of these studies reported higher cure rates in the acupuncture plus another standard treatment group than in the standard treatment alone group. However, while the results of an exploratory meta-analysis of cure rate data from eight trials testing acupuncture versus no acupuncture tended to favour acupuncture, the results were very inconsistent across the studies and the estimated effect was very imprecise (383/396 versus 272/355; RR 1.32, 95% CI 0.95 to 1.84; P value = 0.1; I(2) = 98%).Fourteen studies compared acupuncture with a variety of other non-surgical treatments, such as Chinese drug patches, hot and cold water, ice packs, oral Chinese herbal medicine and elastic bandage. Some studies found in favour of acupuncture, some in favour of the other treatment and some found a lack of evidence for a difference between the two interventions under test. The results of an exploratory meta-analysis of cure rate data from 11 trials testing acupuncture versus another non-surgical intervention tended to slightly favour acupuncture, but these were not statistically significant and the data were very heterogeneous (404/509 versus 416/497; RR 1.07, 95% CI 0.94 to 1.22; P value = 0.30; I(2) = 92%).

AUTHORS' CONCLUSIONS

The currently available evidence from a very heterogeneous group of randomised and quasi-randomised controlled trials evaluating the effects of acupuncture for the treatment of acute ankle sprains does not provide reliable support for either the effectiveness or safety of acupuncture treatments, alone or in combination with other non-surgical interventions; or in comparison with other non-surgical interventions. Future rigorous randomised clinical trials with larger sample sizes will be necessary to establish robust clinical evidence concerning the effectiveness and safety of acupuncture treatment for acute ankle sprains.

Ankle sprains and instability

Ankle injuries are among the most common injuries presenting to primary care providers and emergency departments and may cause considerable time lost to injury and long-term disability. Inversion injuries about the ankle involve about 25% of all injuries of the musculoskeletal system and 50% of all sports-related injuries. Medial-sided ankle sprains occur less frequently than those on the lateral side. High ankle sprains occur less frequently in the general population, but do occur commonly in collision sports. Providers should apply the Ottawa ankle rules when radiography is indicated and refer fractures and more severe injuries to orthopedic surgery as needed.

Increased frequency of ankle sprain does not lead to an increase in ligament laxity

OBJECTIVE

Ankle sprains are the most common injury in the active population. With high reinjury rates and complaints of the ankle "giving way," it has been suggested that laxity of ankle ligaments increases with repeated sprains. The objective of this study was to determine if a relationship exists between ligament laxity and the number of ankle sprains.

DESIGN

Cross-sectional study.

SETTING

Biomechanics laboratory.

PARTICIPANTS

A total of 203 Division I collegiate athletes (84 women; 119 men; age, 18.5 ± 1.1 years; height, 178.5 ± 10.8 cm; mass, 79.8 ± 18.7 kg) participated in the study.

INTERVENTION

Each participant reported the number of previous sprains on each ankle. Ligament laxity was measured using an instrumented ankle arthrometer.

MAIN OUTCOME MEASURES

Measurements for anterior displacement (AD), inversion (IV), and eversion (EV) rotation of the ankle were obtained using an instrumented ankle arthrometer.

RESULTS

There was no relationship between ligament laxity and the number of ankle sprains in either direction (AD, P = 0.86; IV, P = 0.64; EV, P = 0.81). In addition, comparing ligament laxity between previously sprained ankles and ankles that have never been sprained resulted in no differences in the direction of movement (AD, P = 0.98; IV, P = 0.96; EV, P = 0.67).

CONCLUSIONS

Despite anecdotal evidence suggesting repeated ankle sprains increase ligament laxity, this report involving a large data set and a reliable measurement analysis found no relationship between the two. The results of this study make it necessary to rethink the causes of ligament laxity. Therefore, further research is necessary to understand the causes of "giving way" of the ankle and their role in repeated ankle sprains.

National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes

OBJECTIVE

To present recommendations for athletic trainers and other allied health care professionals in the conservative management and prevention of ankle sprains in athletes.

BACKGROUND

Because ankle sprains are a common and often disabling injury in athletes, athletic trainers and other sports health care professionals must be able to implement the most current and evidence-supported treatment strategies to ensure safe and rapid return to play. Equally important is initiating preventive measures to mitigate both first-time sprains and the chance of reinjury. Therefore, considerations for appropriate preventive measures (including taping and bracing), initial assessment, both short- and long-term management strategies, return-to-play guidelines, and recommendations for syndesmotic ankle sprains and chronic ankle instability are presented.

RECOMMENDATIONS

The recommendations included in this position statement are intended to provide athletic trainers and other sports health care professionals with guidelines and criteria to deliver the best health care possible for the prevention and management of ankle sprains. An endorsement as to best practice is made whenever evidence supporting the recommendation is available.

Isolated anterior talofibular ligament Broström repair for chronic lateral ankle instability: 9-year follow-up

BACKGROUND

Lateral ankle sprains may result in pain and disability in the short term, decreased sport activity and early retirement from sports in the mid term, and secondary injuries and development of early osteoarthritis to the ankle in the long term.

HYPOTHESIS

This combined approach to chronic lateral instability and intra-articular lesions of the ankle is safe and in the long term maintains mechanical stability, functional ability, and a good level of sport activity.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We present the long-term outcomes of 42 athletes who underwent ankle arthroscopy and anterior talofibular Broström repair for management of chronic lateral ankle instability. We assessed in all patients preoperative and postoperative anterior drawer test and side-to-side differences, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Kaikkonen grading scales. Patients were asked about return to sport and level of activity. Patients were also assessed for development of degenerative changes to the ankle, and preoperative versus postoperative findings were compared.

RESULTS

Thirty-eight patients were reviewed at an average of 8.7 years (range, 5-13 years) after surgery; 4 patients were lost to follow-up. At the last follow-up, patients were significantly improved for ankle laxity, AOFAS scores, and Kaikkonen scales. The mean AOFAS score improved from 51 (range, 32-71) to 90 (range, 67-100), and the mean Kaikkonen score improved from 45 (range, 30-70) to 90 (range, 65-100). According to outcome criteria set preoperatively, there were 8 failures by the AOFAS score and 9 by the Kaikkonen score. Twenty-two (58%) patients practiced sport at the preinjury level, 6 (16%) had changed to lower levels but were still active in less demanding sports (cycling and tennis), and 10 (26%) had abandoned active sport participation although they still were physically active. Six of these patients did not feel safe with their ankle because of the occurrence of new episodes of ankle instability. Of the 27 patients who had no evidence of degenerative changes preoperatively, 8 patients (30%) had radiographic signs of degenerative changes (5 grade I and 3 grade II) of the ankle; 4 of the 11 patients (11%) with preexisting grade I changes remained unchanged, and 7 patients (18%) had progressed to grade II. No correlation was found between osteoarthritis and status of sport activity (P = .72).

CONCLUSION

Combined Broström repair and ankle arthroscopy are safe and allow most patients to return to preinjury daily and sport activities.

Musculoskeletal conditions of the foot and ankle: assessments and treatment options

Musculoskeletal conditions of the foot and ankle are an important public health challenge due to their increasing incidence combined with their substantial negative impact on patients' quality of life. Non-pharmacological treatments serve as the first line of treatment and are frequently used for patients with musculoskeletal conditions of the foot and ankle. This review provides a summary of the assessments and non-invasive treatment options based upon available evidence. Recent studies show that individuals with foot and ankle pain have multiple co-existing impairments in alignment, motion, load distribution and muscle performance that may be evident in static and/or dynamic tasks. In addition, both clinical and epidemiological studies support the inter-dependence between the foot and proximal joints. For instance, aberrant foot structure has been linked to foot osteoarthritis (OA), as well as OA and pain at the knee and hip. Most recently, advances in motion capture technology and plantar load distribution measurement offer opportunities for precise dynamic assessments of the foot and ankle. In individuals with musculoskeletal conditions of the foot and ankle, the chief objectives of treatment are to afford pain relief, restore mechanics (alignment, motion and/or load distribution) and return the patient to their desired level of activity participation. Given that most patients present with multiple impairments, combinational therapies that target foot-specific as well as global impairments have shown promising results. In particular, in individuals with rheumatoid arthritis and other rheumatic diseases, comprehensive rehabilitation strategies including early detection, foot-based interventions (such as orthoses) and wellness-based approaches for physical activity and self-management have been successful. While significant improvements have been made in the last decade to the assessment and treatment of foot and ankle conditions, few randomised clinical trials specifically have investigated patients with foot or ankle conditions to provide global insights into this area. Consequently, current recommendations vary based upon the scope of studies presented in this review as well as the strength of studies. This review indicates a need for more in-depth investigations into the components of assessment and treatment options for foot and ankle musculoskeletal conditions.

The Swedish version of OMAS is a reliable and valid outcome measure for patients with ankle fractures

Background

The aim of this study was to evaluate the test-retest reliability and the validity of the self-reported questionnaire Olerud-Molander Ankle Score (OMAS) in subjects after an ankle fracture.

Methods

When evaluating the test-retest reliability of the OMAS, 42 subjects surgically treated due to an ankle fracture participated 12 months after injury. OMAS was completed by the patients on two occasions at one to two weeks’ interval. Concurrent criterion validity was evaluated using the five subscales of the Foot and Ankle Outcome Score (FAOS) and global self-rating function (GSRF), which is a five-grade Likert scale with the alternatives: “very good”, “good”, “fair”, “poor”, “very poor”. Forty-six patients participated in the validation against FAOS, and for GSRF 105 patients participated at 6 months and 99 at 12 months. Uni-, bi- and trimalleolar fractures were all included and both non-rigid and rigid surgical techniques were used. All fractures healed without complications. Before analysis of the results the five groups according to GSRF were reduced to three: “good”, “fair” and “poor”. Test-retest reliability was assessed using Spearman’s rank correlation, the intraclass correlation coefficient (ICC), the standard error of measurement (SEM and SEM%) and the smallest real difference (SRD and SRD%). The Cronbach’s alpha score and validity versus FAOS was assessed using Spearman’s rank correlation and validity versus GSRF using the Kruskal-Wallis Test and the Mann–Whitney U-Test as ad hoc analyses.

Results

The test-retest reliability correlation coefficient obtained was rho = 0.95 and ICC = 0.94. The SEM was 4.4 points and SEM% 5.8% and should be interpreted as the smallest change that indicates a real change of clinical interest for a group of subjects. The SRD was 12 points and SRD% 15.8% and should be interpreted as the smallest change that indicates a real change of clinical interest for a single subject. The correlation coefficients versus the five subscales of FAOS ranged from rho = 0.80 to 0.86. There were significant differences between GSRF groups “good”, “fair” and “poor” (p < 0.001) at both the six-month and the 12-month follow-up. The internal consistency for the OMAS was 0.76. The effect size between results from 6-month and 12-month follow-up turned out be 0.44 and should be considered as medium.

Conclusion

The results showed that the test-retest reliability of the Swedish version of OMAS was very high in subjects after an ankle fracture and the standard error of measurement was low. Furthermore the OMAS was found to be valid using both the five subscales of FAOS and the GSRF. The OMAS can thus be used as an outcome measure after an ankle fracture.

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.

Instrumentos de avaliação para limitações funcionais associadas à instabilidade crônica de tornozelo: uma revisão sistemática da literatura

A instabilidade de tornozelo é definida como a sua tendência para sofrer falseios e entorses de repetição após a ocorrência de entorse lateral. Como a presença de instabilidade é definida por meio das queixas relatadas pelo indivíduo, apresenta caráter subjetivo, sendo importante identificar o melhor instrumento de avaliação para a determinação de sua presença e/ou gravidade. O objetivo deste estudo foi revisar, de forma sistemática, instrumentos de avaliação concebidos para pacientes com instabilidade crônica de tornozelo. Foram realizadas pesquisas bibliográficas nas bases de dados PubMed, Embase, BVS, LILACS e SciELO para identificar os instrumentos elegíveis. No total, seis estudos foram incluídos e apresentaram cinco instrumentos diferentes - Foot and Ankle Disability Index (FADI), Ankle Joint Functional Assessment Tool (AJFAT), Foot and Ankle Ability Measure (FAAM), Ankle Joint Functional Assessment Tool (AII) e Cumberland Ankle Instability Tool (CAIT). Foram encontrados instrumentos com qualidade que detectam limitações funcionais em indivíduos com instabilidade crônica de tornozelo, não sendo instrumentos válidos para diagnóstico de instabilidade. O CAIT mostrou-se a ferramenta mais completa, mas não foi validada em uma população específica de indivíduos com condição de instabilidade do tornozelo. Observa-se a necessidade de mais estudos clinimétricamente válidos a fim de atestar a sua validade para se obter uma ferramenta eficaz e completa da instabilidade funcional do tornozelo.

Development of the patient-based outcome instrument for foot and ankle: part 2: results from the second field survey: validity of the Outcome Instrument for the foot and ankle version 2

BACKGROUND

The Clinical Outcomes Committee of the Japanese Society for Surgery of the Foot (JSSF) has conducted the second Field Survey of the Outcome Instrument for the Foot and Ankle version 2.

METHODS

The survey of the Outcome Instrument version 2, which was composed of 43 items, was performed in 313 patients (154 men and 159 women) who had pathological conditions related to the foot and ankle. Optional sports items in the Outcome Instrument version 2 were analyzed in 123 patients. Internal consistency and construct validity of the Outcome Instrument version 2 were assessed. Correlation of the Outcome Instrument version 2 score with Short Form 36 (SF36) and JSSF scores was analyzed to evaluate criterion validity.

RESULTS

Both the EFA and CFA demonstrated good alignment of questionnaire items with their intended subscales in most cases. Sports items were not clearly classified into subgroups. Therefore, it seemed reasonable to use those as a set of questions in a single subscale. The present subscales, having similar names as the SF36 subscales, were closely correlated with the respective subscales. In those cases, the magnitude of the correlation coefficient was >0.6 (p < 0.001) except the present subscale called General Health and Well-being. Comparison of the present scores with JSSF evaluation scores showed satisfactory results except in patients with rheumatoid arthritis.

CONCLUSIONS

The Outcome Instrument version 2 demonstrated acceptable psychometric performances as outcome measures for patients with pathological conditions related to the foot and ankle. This outcome instrument would be helpful to evaluate patients with foot and/or ankle impairment. However, the analyses of the test-retest reliability and the influence of background factors such as age and gender, etc., on Outcome Instrument version 2 are needed in the third field survey.

Clinical results and functional evaluation of the Chrisman-Snook procedure for lateral ankle instability in athletes

There is no consensus regarding optimum surgical treatment for chronic ankle instability. The purpose of this study is to describe a variation of the Chrisman-Snook lateral ligament reconstruction that the senior author uses in patients with chronic ankle instability recalcitrant to conservative management. All patients who underwent reconstruction from 1997 to 2006 were identified, and those with a minimum 2-year follow-up were included, representing a total of 44 ankles in 43 patients. All underwent clinical evaluation and completion of the Foot and Ankle Outcome Survey and the Kaikkonen Scale. At mean follow-up of 4.4 years, mean dorsiflexion loss was 2° compared with the nonoperative side. The postoperative mean Foot and Ankle Outcome Survey score was 74 ± 16 (range, 36-98), while the mean Kaikkonen total score was 77 ± 14 (range, 40-95). Thirty-eight patients (84.6%) were satisfied with their result. Six patients (13.6%) underwent reoperation, including 4 with peroneal tendon scarring requiring tenolysis. Return to sport was achieved in 28 of 35 patients (80%) at a median of 6 months postoperatively. It is concluded that dorsiflexion loss can be minimized and return to sport expected in most patients following this variation of the Chrisman-Snook reconstruction.

Validity and responsiveness of the ankle function score after acute ankle injury

The purpose of this study was to examine prognostic validity, concurrent validity and responsiveness of ankle function score (AFS) for patients with acute ankle injury. In a prospective cohort study, AFS was compared with Olerud and Molander ankle score (OMAS), patient-specific complaints (PSC), and global perceived effect. Sensitivity and specificity were calculated to estimate prognostic validity; correlation was calculated for concurrent validity. Effect Size, Standardized Response Mean, and Responsiveness Ratio were calculated to estimate responsiveness. The sensitivity of AFS was 76% and the specificity was 57%. Correlation between AFS and OMAS at baseline, end of treatment and difference was 0.82, 0.70 and 0.79, respectively. Outcomes for responsiveness of AFS were comparable to outcomes for OMAS and PSC. This study found limited evidence for the AFS as a prognostic and evaluative instrument. The AFS is a simple instrument based on basic functional outcomes (pain, stability, weight bearing, swelling and gait) and may be used in addition to subjective clinical judgment as a prognostic and evaluative tool for recovery after acute ankle injury.

Surgical versus functional treatment for acute ruptures of the lateral ligament complex of the ankle in young men: a randomized controlled trial

BACKGROUND

Some have recommended surgical treatment of Grade-III lateral ligament injuries in very active individuals with high functional demands on the ankle. The purpose of this study was to establish whether surgery provides better long-term results than functional treatment for acute ruptures of the lateral ligaments of the ankle.

METHODS

Physically active Finnish men (mean age, 20.4 years) with an acute Grade-III lateral ligament rupture of the ankle were randomly allocated to surgical (n = 25) or functional (n = 26) treatment. Ligament injury was confirmed with stress radiographs. Surgical treatment comprised suture repair of the injured ligament(s) within the first week after injury. A below-the-knee plaster cast was worn for six weeks with full weight-bearing. Functional treatment consisted of the use of an Aircast ankle brace for three weeks. The main outcome measures included final follow-up examinations, calculation of an ankle score, stress radiographs, and magnetic resonance imaging scans.

RESULTS

Fifteen (60%) of twenty-five surgically treated patients and eighteen (69%) of twenty-six functionally treated patients returned for long-term follow-up (mean duration, fourteen years). All patients in both groups had recovered their preinjury activity level and reported that they could walk and run normally. The prevalence of reinjury was one of fifteen in the surgical group and seven of eighteen in the functional treatment group (risk difference: 32%; 95% confidence interval: 6% to 58%). The mean ankle score did not differ significantly between the groups (mean difference: 8.3 points; 95% confidence interval: -0.03 to 16.6 points). Stress radiographs revealed no difference between groups with regard to the mean anterior drawer (-1 mm in the surgical group and 0 mm in the functional treatment group; mean difference: 0.7 mm; 95% confidence interval: -1.4 to 2.7 mm) or mean tilt angle (0° in both groups; mean difference: 0.1°; 95% confidence interval: -3.2° to 3.5°). Grade-II osteoarthritis was observed on magnetic resonance images of four of the fifteen surgically treated patients and in none of the eighteen functionally treated patients (risk difference: 27%; 95% confidence interval: 4% to 49%).

CONCLUSIONS

These findings indicate that, in terms of recovery of the preinjury activity level, the long-term results of surgical treatment of acute lateral ligament rupture of the ankle correspond with those of functional treatment. Although surgery appeared to decrease the prevalence of reinjury of the lateral ligaments, there may be an increased risk for the subsequent development of osteoarthritis.

Plyometric training versus resistive exercises after acute lateral ankle sprain

BACKGROUND

Plyometric training is a widely used method to improve performance in healthy athletes. It is highly recommended in the late stage of rehabilitation of many lower limb injuries. However, its effects on muscle strength and function in management of lateral ankle sprain have not been reported. Therefore, the objective of the current study was to determine the effects of plyometric training versus resistive exercises on muscle strength and function following acute lateral ankle sprain.

MATERIALS AND METHODS

Twenty-two athletes (aged from 20 to 35 years) of both sexes with grade I or II unilateral inversion ankle sprain participated in the study (at least 3 weeks after acute injury). They were randomly assigned to two groups. The first group received plyometric training, whereas the second one received resistive training for 6 weeks. Isokinetic peak torque/body weight for invertors and evertors at 30 degrees/s and 120 degrees/s and functional tests were assessed before and after training.

RESULTS

Both plyometric and resistive training improve isokinetic evertor and invertor peak torques and functional performance of athletes p < 0.05. There were no significant differences between groups concerning peak torque/body weight for invertors and evertors at both speeds measured p > 0.05. The functional test measures of the plyometric group were significantly higher than that of resistive group.

CONCLUSION

Plyometrics were more effective than resistive exercises in improving functional performance of athletes after lateral ankle sprain.

Instrumentos clínicos de avaliação funcional do tornozelo: revisão sistemática

A entorse lateral do tornozelo é umas das lesões mais comuns em atletas e adultos fisicamente ativos. A utilização de instrumentos de avaliação confiáveis e válidos é fundamental na determinação da intervenção terapêutica adequada e, portanto, do sucesso do tratamento. O objetivo deste trabalho foi fazer um levantamento crítico, por meio de uma análise sistemática da literatura, dos instrumentos de medida adequados (questionários e escalas funcionais) disponíveis para a avaliação dos indivíduos que sofreram entorse lateral do tornozelo. Após busca nos bancos de dados Medline e Scielo foram incluídos 11 questionários para avaliação funcional do tornozelo. A escala funcional de extremidade inferior LEFS (Lower extremity functional scale) e a medida funcional de pé e tornozelo FAAM (Foot and ankle ability measure) foram as que apresentaram melhor qualidade metodológica, além de mais informações sobre suas propriedades de medida e suas aplicações práticas - mas não foram traduzidas para o português. Foram encontrados dois questionários traduzidos e adaptados para a população brasileira, o instrumento de instabilidade de tornozelo CAIT (Cumberland Ankle Instability Tool) e a escala de tornozelo e retropé AOFAS (American Orthopaedic Foot and Ankle Society - ankle-hindfoot scale). A AOFAS apresentou uma análise mais completa de suas propriedades, sendo portanto o instrumento mais recomendado para avaliação funcional do complexo pé-tornozelo atualmente no Brasil.