Foot & Ankle Fractures

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2 Foot & Ankle Fractures Partial/Complete break in any bones of the foot or bones around ankle i.e. medial & lateral malleoli Prevalence ~2/1000 per year, 14,000 cases in HK per year 2 ~9% of all injuries occur in workplace 1 Recovery Usually takes 6-8 weeks for bones to heal, some even take up to 2 years AAOS 2007 Grimm JD & Fallet L 1999

3 Foot & Ankle Fractures Causes Direct trauma e.g. twisting, direct blow Overuse i.e. stress fracture Signs & Symptoms Pain Swelling & Bruising Unable to bear weight Sometimes with deformity Management --- depends on type & severity Conservative Treatment: Closed reduction to restore alignment followed by immobilization, mainly for stable fracture Surgical Treatment: Reduction & internal/external fixation with screws, plates or wires, mainly for unstable/non-union fracture AAOS

4 Traditional Treatment Approach for Fractures Fracture occur RICE - Swelling - Pain Conservative Treatment Surgical Treatment Immobilized in cast for 6-8 weeks Traditionally, no other alternatives to keep patient mobile while protecting fracture site at the same time However, prolonged immobilization: results in undesirable outcomes affects strength of the healing bone

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6 Undesirable Outcomes of Casting Muscle atrophy 11 Calf muscle size & force are reduced by 20%-32% & 40-53% respectively in patients with ankle fractures after 6-8 weeks of cast immobilization Muscle performance can only be reversed with 10 weeks of supervised physical therapy Joint Stiffness 18 Muscles & tendons become short and inextensible after immobilization Stiffness and torque of passive ankle movement take >3 months to recover Possible Complications of Casting e.g. Compartment syndrome, dermatitis Shaffer MA et al 2000 Nightingale EJ et al 2007

7 Complications of Cast or Splint Immobilization Compartment syndrome Ischemia Heat injury Pressure sores and skin breakdown Infection Dermatitis Neurologic injury Ischemia Compartment syndrome Pressure sores and infection Dermatitis note: Listed in order from most clinically relevant to least clinically relevant.

8 Wolff s Law - Bone Healing Bone will adapt to the loads it is placed under. If loading on a particular bone increases, the bone will remodel itself over time to become stronger to resist that sort of loading. If the loading on a bone decreases, the bone will become weaker due to turnover Early mobilization - application of stress allows bones and ligaments to heal better and stronger Without weight bearing Loss of bone density Key:

9 Wolff s Law - Examples Increases loading stronger bone & soft tissue Decreases loading weaker bone (osteoporosis) & soft tissue (atrophy)

10 Aircast Pneumatic Walking Brace--- Allows early mobilization Allows mobilization while providing protection to injured part by the semi-rigid shells & custom-inflated aircells Pulsating, graduated compression during walking to help reduce edema for faster healing. Adjustable & customizable --- adapt to sizes of limbs with individually inflated aircells. 16 Dale PA et al Kalish SR et al Stover & York 1979 Removable for investigation & exercise Recommendation for lower leg fracture: Early motion to prevent stiffness, when starts to WB, most likely need to use crutches or a walker 16 AAOS 2010

11 ONLY Aircast Walkers have all the clinical studies prove its claimed efficacy

12 For reduction of gastrocnemius muscle activity, the Aircast FP Walker was more effective than cast. Aircast Walkers Proven Clinical Outcome patients in Walker recovered 3 weeks earlier and returned to work 8 days earlier than those in cast Functional Outcome of Surgery for Fractures of the Ankle time from surgery to return to work was 50% lower in the Walker group than in the casted group: 53 days vs. 106 days. (Koval et al, JBJS 2000) a pressurized brace yields a stronger healed fracture than cast Pneumatic Walker resulted in a significantly diminished incidence of lower extremity atrophy and osteoporosis

13 Achilles Tendon Tendinopathy /Rupture Achilles Tendon Rupture, Current Concepts in Orthopaedics, 2008 Achilles Tendinopathy, Current Concepts in Orthopaedics, 2010 Conservative treatment (Non Operative) ESSKA - Pneumatic Walker is preferred over cast (4-12 weeks) Functional management of Achilles tendon rupture: A viable option for non-operative management. S. Karkhanis et al, Foot and Ankle Surgery Int Of the 107 Achilles tendons, 105 (98%) healed with an average discharge time of 22 weeks. complication rate is 11%, compare with 24% by surgical treatment. Surgical Management - Post-op: Pneumatic walker is preferred over cast for 4-8 weeks. Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures. A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation K Willits et al JBJS, Vol 92-A, No.17, Dec 2010 Similar clinical outcomes & less complications with non-operative functional treatment vs operative treatment of Achilles Tendon Rupture

14 AirSelect Walker vs Pneumatic Walker

15 Gait (Walking) Cycle The gait cycle extends from heel strike to heel strike of one leg and includes the stance and swing phases of both legs. Functional Management of Walker 62% 38 %

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18 Competition - Stick-Foam Walkers Poor support No circumferential, Semi-Rigid Shell Less protection of the limb for external force No functional management No benefit from clinically proven Duplex Aircells technology No support by Aircells, extremity has a tendency to shift in the boot, resulting in shear stress on the lower limb and affects healing Bledsoe The competitors walkers no optimal rocker sole. Rocker sole on Aircast walker provides superior walking gait (R&D with gait analysis) Breg

19 Aircast Airselect vs Ossur Rebound

20 Knee flexion/extension Ossur: increased knee flexion during swing phase To ensure foot clearance More energy expenditure Aberrant from normal gait pattern Earlier fatigue

21 Aircast Vs Ossur Centre of Pressure medial-lateral considerably more laterally located centre of pressure in the Ossur Rebound Ground reaction force more lateral in Ossur Foot position more external rotation in Ossur may cause strain on the MCL and discomfort to the knee

22 Knee moments Extension moment when the body moves over the stance limb (before toe-off) is considerably high with the Ossur Walker and could cause hyperextension In healthy knee hyperext is prevented by hamstrings. In pathologic or fatigue knee balanced muscle activity may be compromised and hence the hyperextension may persist and cause pain.

23 Aircast Airselect vs VACO cast

24 Cost-Effectiveness Reduction in both Direct & Indirect Health-care Costs $ Shorter hospital stay 3 Simanski CJP 2006 the patients in the cast immobilization group stayed 3 days longer in the hospital than the early WB group $ Currently the lowest charge per bed (Private hospital): $ /day $ This treatment strategy saves $

25 Cost Utility Re-cast $ Cast will become loosened as the swelling goes down or when atrophy occurs. Loosened cast has lost its functions and becomes an extra burden to the limb. Thus it needs to be changed frequently $ Initial cost: US$ Cooke MW et al 2009 $ Re-cast: 23 Sprague S et al 2002 $ Removal of cast: $ Each re-casting costs: US$ Verity AAOS 2007 $ Clinical re-visit after re-cast to make sure no complications occur Time-consuming More days of absence from work

26 Reduced Lose in Labor Productivity $ Earlier return to work & sports 7 Egol KA 2000, 3 Simanski CJP Whitelaw JG 1991 the mean time from surgery to return to work was 53.3 days for early mobilization with functional brace group and days for cast immobilization group Return to work 53 Days earlier Minimum Cost of absence from work: ~US$30/Day (Minimum Wage in HK) Early motion with pneumatic walking brace saves society: ~US$1500

27 Functional Manageme Better Quality of Life: More mobile Able to self-care Earlier return to daily activities & work Less pain/discomfort/complications Possibly les anxiety/depression Better quality of life ED-5D Questionnaire A standardised, generic measure of health status for clinical and economic appraisal Functional bracing allows early mobilization, thus ensures patients to have good QoL in at least 4 out of 5 dimensions

28 Early mobilization is the key with walking brace Better Clinical Outcomes Better ankle functions Improved bone healing Lower Risk of Complications More Cost-Effective Shorter hospital stay Reduced Lose in Labor Productivity Earlier return to work Better Quality of Life Earlier return to daily activities & sports

29 References 1. Injuries of the Foot and Ankle in Occupational Medicine: A 1-Year Study Grimm DJ & Fallet L, The Journal of Foot & Ankle Surgery 38(2): , Ankle Fractures American Academy of Orthopaedic Surgeons(AAOS) Functional Treatment and Early Weightbearing After an Ankle Fracture: AProspective Study Simanski CJP et al., J Orthop Trauma 20(2): , Use of a Cast Compared with a Functional Ankle Brace After Operative Treatment of an Ankle Fracture: A Prospective, Randomized Study Lehtonen H et al., Bone Joint Surg. 85A(2): , The Law of Bone Remodeling Wolff J., Berlin Heidelberg: New York: Springer, Tibia (Shinbone) Shaft Fractures American Academy of Orthopaedic Surgeons(AAOS) Functional outcome of surgery for fractures of the ankle: a prospective, randomised comparison of management in a cast or a functional brace Egol KA et al., J Bone Joint Surg. 82B(2): , The Aircast Walking Brace versus Conventional Casting Methods: A Comparison Study Kalish SR et al., Journal of the American Podiatric Medical Association 77(11): , The Aircast/AirStirrup System for Graduated Management of Lower Extremity Injuries Stover CN & York JM, Scientific Exhibit Paper, AAOS, San Francisco, Comparison of Two Conservative Methods of Treating an Isolated Fracture of the Lateral Malleolus Port AM et al., J Bone Joint Surg 78B(4): , Effects of Immobilization on Plantar-Flexion Torque, Fatigue Resistance, and Functional Ability Shaffer MA et al., PHYS THER 80(8): , Following an Ankle Fracture Early Weight Bearing After Posterior Malleolar Fractures: An Experimental and Prospective Clinical Study Papachristou G et al., The Journal of Foot & Ankle Surgery 42(2): , 2003

30 References 13. Mobilization after operation of ankle fractures: Good results of early motion and weight bearing Ahl T et al., Acts Orthop Scand 59(3): , The Effect of a Pneumatic Leg Brace on Return to Play in Athletes with Tibial Stress Fractures Swenson EJ et al., Am J Sports Med 25(3): , A Pneumatic Leg Brace for the Treatment of Tibial Stress Fractures Whitelaw GP et al., Clinical Orthopaedics and Related Research 270: , A new Concept in Fracture Immobilization: The Application of a Pressurized Brace Dale PA et al., Clinical Orthopaedics and Related Research 295: , Effects of Intermittent Pneumatic Soft-Tissue Compression of Fracture-Healing in an Animal Model Park SH & Silva M, J Bone Joint Surg 85A(8): , Passive Dorsiflexion Flexibility after Cast Immobilization for Ankle Fracture Nightingale EJ et al., Clinical Orthopaedics and Related Research 456: 65-69, AAFP 2009 Splints and Casts: Indications and Methods Boyd A et al., Am Fam Physician 80(5): , Stress Fracture of the Foot and Ankle American Academy of Orthopaedic Surgeons (AAOS) Update on Acute Ankle Sprains Tiemstra J D, Am Fam Physician 85(12), Treatment of severe ankle sprain: a pragmatic randomized controlled trial comparing the clinical effectiveness and cost-effectiveness of the three types of mechanical ankle support with tubular bandage. The CAST trial Cooke MW et al., Health Technology Assessment 13(13): 1-121, An economic evaluation of early versus delayed operative treatment in patients with closed tibial shaft fractures Sprague S et al., Arch Orthop Trauma Surg 122 : , Treatment of Charcot foot and ankle with a prefabricated removable walker brace and custom insole. Verity S et al., Foot and Ankle Surgery 268:1-6, 2007