Session 7: Foot and Ankle
Torsdag den 24. oktober
09:30 - 10:30
Lokale: Vingsal 1
Chairmen: Ellen Hamborg-Petersen og Jens Kurt Johansen
55. A new passive movement model for the treatment of non-healing diabetic foot ulcers. A randomized clinical trial of wound healing
Tue Smith Jørgensen, Maria Leinum, Hans Gottlieb, Stig Brorson, Ylva Hellsten, Birgitte Høier
Orthopedic, sport and foot surgery, Gentofte; Nutrition exercise and sports, university of copenhagen; Orthopedic, Herlev Hospital; Orthopedic, Zealand university Hospital; Nutrition exercise and sports, university of copenhagen; Nutrition exercise and sports, university of Copenhagen
Background: Diabetic foot ulcers are a frequent and
serious complication in diabetes.
Exercise can promote wound healing
but as, many of the patients have poor
exercise tolerance, passive movement
may be an alternative.
Purpose / Aim of Study: To evaluate the effect of 8 weeks of
passive movement training of both legs
on wound healing in patients with non-
healing diabetic foot ulcers.
Materials and Methods: Twenty-one patients were included in a
randomized, controlled, clinical trial
with two-leg passive movement.
Wound healing, patient compliance,
femoral blood flow, blood samples,
functional tests and muscle proteins
related to vascular function and
angiogenesis were assessed.
Findings / Results: 16 participants completed the trial.
Two participants from the intervention
group and two from the control group
were excluded due to adverse events
not related to the intervention. There
was a clinically, but not statistically,
significant improvement of 40% in
wound healing (p=0.062) with the
passive movement intervention. There
was a significant negative correlation
(p=0.037) between the duration of the
wound at baseline and wound area
reduction after the eight-week
intervention period. The intervention
did not alter blood flow, and there was
no change in measured angiogenic or
vascular proteins.
Conclusions: The intervention was well tolerated and
had a clinically significant effect on
wound healing. The modality has
potential as an effective first line
treatment in diabetic patients with
reduced physical abilities to accelerate
healing of non-healing ulcers.
56. Calcaneal positioning in equinus immobilization of the ankle joint. A comparsion of common orthoses used in the treatment of acute Achilles tendon ruptures
Rasmus Mikkelsen, Sanja Somodi, Per Hölmich, Kristoffer Barfod
Artroskopisk Center, SORC-C, Hvidovre Amager Hospital ; Radiologisk afdeling, Herlev og Gentofte Hospital; Artroskopisk Center, SORC-C, Hvidovre Amager Hospital ; Artroskopisk Center, SORC-C, Hvidovre Amager Hospital
Background: Orthoses are an important part of both conservative
and operative treatment of acute Achilles tendon
rupture. It is believed to be of critical importance to
position the foot in equinus in order to protect the
torn tendon from strain and allow the tendon to heal
in correct length.
Purpose / Aim of Study: The aim of the study was to test four different
orthoses, commercially available and commonly
used in treatment of acute Achilles ruptures.
Materials and Methods: Lateral radiographs were taken of the right ankle
and foot in 5 healthy study participants. Each
participant had 11 true lateral radiographs taken:
One of the ankle joint in neutral position. One of a
circular equinus cast (CEC). Three of an adjustable
equinus boot (VACOped) with the foot in 30°, 15°
and 0° of plantar flexion, respectively. Three of a
DJO AirSelect Standard boot with 3, 2 and 1 Aircast
Achilles wedge (AAW), respectively. And finally,
three of a DJO AirSelect Standard boot with 3, 2
and 1 BREG wedges, respectively. The radiographs
were analyzed by a radiologist for the following two
radiographic measurements: The tibiocalcanar
angle (TCA) and the Achilles Relief Distance (ARD).
Findings / Results: The lateral radiographs showed a mean (SD) TCA
of 86 (7,8) in CEC, 76 (7,3) with 3 AAW, 90 (6,9)
with 3 BREG wedges and 84 (6,6) in the VACOped
in 30 of plantarflexion. There was significant greater
TCA using VACOped (p<0.01) and 3 BREG
(p<0.01) compared to 3 AAW.
The mean ARD (SD) was 10mm (6,6) in CEC,
19mm (5,5) with 3 AAW, 7mm (4,5) with 3 BREG
and 12mm (4,6) using VACOped in 30.
ARD was significantly lower in CEC (p<0.05), 3
BREG (p<0.01) and VacoPed 30 (p<0.05) compared
to 3 AAW.
No difference was shown comparing 1 vs 3 AAW´s
in ARD (p=0,18) with a mean of 22,6 mm and 19,0
mm respectively.
Conclusions: The study found that CEC, 3 BREG and VACOped
30 produced significantly better equinus compared
to 3 AAW. We believe the difference to be of clinical
relevance in the treatment of acute Achilles tendon
ruptures.
57. How can we implement Early Functional Rehabilitation for Achilles tendon ruptures if the original studies didn¡¯t describe what they did? A systematic review
Marianne Christensen, Jennifer A Zellers, Inge Lunding Kjær, Karin Grävare Silbernagel, Michael Skovdal Rathleff
Physiotherapy and Occupational Therapy, Orthopaedic Research Unit, Department of Clinical Medicine, Aalborg University Hospital; Department of Physical Therapy, University of Delaware, USA; Orthopaedic Research Unit, Aalborg University Hospital; Department of Physical Therapy, University of Delaware, USA, Department of Orthopaedics, University of Gothenburg, Sweden; Physiotherapy and Occupational Therapy, Aalborg University Hospital
Background: Achilles tendon rupture is associated
with long-term deficits in lower leg
muscle strength and function which
impairs the ability to participate in
sport, physical activity and physically
demanding work. Irrespective of
surgical or non-surgical treatment,
Early Functional Rehabilitation (EFR)
is recommended after initial treatment.
Resistance exercise is a key
component of EFR, but no synthesis of
the specific exercises exists.
Purpose / Aim of Study: To describe the resistance exercises
used in EFR in the treatment for acute
Achilles tendon rupture and to
investigate the completeness of the
exercise descriptions.
Materials and Methods: A systematic review was performed in
MEDLINE, Embase, PEDro, CINAHL
and Cochrane. Inclusion criteria were
RCTs, cohort studies and case series
(¡Ý10 participants) using resistance
exercise in the immobilization period
within eight weeks after Achilles
tendon rupture. Completeness of the
exercise description in the publications
was assessed with the CERT and the
Toigo & Boutellier exercise reporting
checklists.
Findings / Results: 38 studies were included, containing
51 different programs with resistance
exercises. Twenty consisted of
isometric exercise, 6 used heel-rises,
13 used strengthening with external
resistance and 12 were unspecified.
None of the studies reported all items
of the reporting checklists. Repetitions
and sets were described in 6 of the 51
interventions. The completion of CERT
were median (IQR) 8(6;10) of the 19
items possible. Completion of Toigo
and Boutellier were 2(1;3) of the 13
items possible.
Conclusions: Resistance exercise as part of EFR
captures a variety of approaches
targeted at training the ankle plantar
flexors, however, this review highlights
the inadequate description of these
interventions. When even the most
common exercise descriptors are
lacking it presents a substantial
obstacle in implementing evidence-
based exercise in clinical practice.
58. Defining components of Early Functional Rehabilitation for acute Achilles tendon rupture: A systematic review
Marianne Christensen, Jennifer A Zellers, Inge Lunding Kjær, Michael Skovdal Rathleff, Karin Grävare Silbernagel
Physiotherapy and Occupational Therapy, Orthopaedic Research Unit, Department of Clinical Medicine, Aalborg University Hospital; Department of Physical Therapy, University of Delaware, USA; Orthopaedic Research Unit, Aalborg University Hospital; Physiotherapy and Occupational Therapy, Aalborg University Hospital; Department of Physical Therapy, University of Delaware, USA, Department of Orthopaedics, University of Gothenburg, Sweden
Background: Early functional rehabilitation is a key
feature in treatment of Achilles tendon
rupture, but there is a lack of
consistency in what defines early
functional rehabilitation across studies.
Purpose / Aim of Study: To define early functional rehabilitation
when used to treat Achilles tendon
rupture, and to identify outcome
measures evaluating the effect of
treatment.
Materials and Methods: 174 studies (published 1979-2018)
were included. Studies rated a median
(IQR) of 17(15-20) on the Downs &
Black. Early functional rehabilitation
incorporated weight bearing (95%),
range of motion (73%) and
isometric/strengthening exercise
(50%). Weight bearing was initiated
within the first week, whereas exercise
(i.e. ankle range of motion,
strengthening, whole body
conditioning) was initiated in the
second week. Initiation of exercises
varied based on whether treatment
was nonsurgical (3.0(2.0-4.0)weeks),
simple (2.0(0.0-2.3)weeks), or
augmented surgical repair (0.5(0.0-2.8)
weeks)(p = 0.017). Functional
outcomes were reported in 130
studies, including ankle range of
motion (n=84) and strength (n=76).
Other outcome domains included
patient reported outcomes (n=89),
survey-based functional outcomes
(n=50), and tendon properties (n=53).
Findings / Results: 174 studies (published 1979-2018)
were included. Studies rated a median
(IQR) of 17(15-20) on the Downs &
Black. Early functional rehabilitation
incorporated weight bearing (95%),
range of motion (73%) and
isometric/strengthening exercise
(50%). Weight bearing was initiated
within the first week, whereas exercise
(i.e. ankle range of motion,
strengthening, whole body
conditioning) was initiated in the
second week. Functional outcomes
were reported in 130 studies, including
ankle range of motion (n=84) and
strength (n=76).
Conclusions: Early functional rehabilitation includes
weight bearing and a variety of
exercise-based interventions initiated
within the first 2 weeks following acute
Achilles tendon rupture. Because early
functional rehabilitation has lacked a
standardised definition, interventions
and outcome measures are highly
variable and pooling data across
studies should be done with attention
to what was included in the
intervention and how treatment was
assessed.
59. The Achilles tendon Total Rupture Score – a manual of how to use it
Hansen Maria Swennergren , Helander Katarina Nilsson , Karlsson Jon
Physical Medicine & Rehabilitation Research-Copenhagen (PMR-C); Department of Physical and Occupational Therapy, Copenhagen University Hospital Amager-Hvidovre, Denmark.; Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden.; Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden.
Background: The Achilles tendon Total Rupture Score (ATRS) is a
commonly used patient reported outcome in patients
with an acute Achilles tendon rupture. The score
contains ten items of which the last three concerns
tasks that some patients cannot and some do not
perform. No manual for the use of ATRS has been
developed. The purpose was to investigate how
ATRS responds at 4, 12 and 24 months after rupture
and develop a manual for the use of ATRS.
Purpose / Aim of Study: This study has a mixed method. The first part
was performed as a retrospective registry study
analysing prospectively gathered data from the
Danish Achilles tendon Database. The data was
gathered 4, 12 and 24 months after rupture. The
original score based on 10 items was compared
with a score based on the first 7 items adjusted
to the same scale as the original score. Density-
and scatterplots were made and differences
between the scores were tested by t-test or
Mann–WhitneyU test. The second part has an
explorative design where a manual to ATRS was
developed. To validate some of the changes in
the manual, patient involvement is used in a
focus group interview.
Materials and Methods: 2790 completed ATRS scores were included. The 7-
item score statistically significantly overestimated
the value of the 10 items score at all time points
(p<0.001) but only at 4 months a clinically relevant
difference was found (9.7points).
Findings / Results: The original ATRS needs to specified and updated.
Conclusions: When ATRS is used for evaluation within the first 4
months after injury, the results are skewed due to a
problem with the last three items. Based on this
finding, a manual for the use of ATRS was
developed including an updated version of ATRS.
60. Charcot Foot Reconstruction – How Does Hardware Failure And Non-union Affect The Clinical Outcome?
Ingvild Kummen, Ngwe Phyo , Venu Kavarthapu
Department of Orthopedics/ Diabetic Foot Clinic, Kings College Hospital, London, UK; Department of Orthopedics/ Diabetic Foot Clinic, Kings College Hospital, London, UK; Department of Orthopedics /Diabetic Foot Clinic,
Background: Surgical reconstruction of the most severe Charcot
foot or ankle deformities using internal fixation has
become a more and more commonly used option.
However, there has been a concern that this carries
a higher risk of major hardware failure.
Purpose / Aim of Study: The aim of our study was to look at the
demographics of hardware failure and non-union in
Charcot midfoot and hindfoot reconstructions, the
radiological and clinical outcomes in those with and
without hardware failure.
Materials and Methods: We retrospectively reviewed our 78 patients with the
mean age of 56.5 years ±11.59 years that have
undergone reconstruction of Charcot deformity
affecting the midfoot, hindfoot or both, between
October 2007 and December 2017. Minimal follow
up was 1 year. We looked at the patients
demographics, radiological bone union and ability to
ambulate.
Findings / Results: 19/78 (24.4%) patients had major hardware failure.
14/25 (56.0%) of the patients who underwent
combination hindfoot and midfoot surgery had
hardware failure, in comparison to 5/53 (9.4%) in
cases with surgery in either hindfoot or midfoot (p <
.001). 7/19 (36,8%) patients developed full fusion
radiologically, compared to 49/59 (83.1%) of the
non-hardware failure patients (p < .001). In the
hardware failure group 9/19 (47.4%) were able to
weight bear in shoes, in comparison to 43/59
(72.9%) in the non-hardware failure patients
(p=.040). 10/19 (52.6%) patients from the hardware
failure group needed a cast or orthosis to ambulate
compared to 11/59 (18.6%) in the non-hardware
failure group (p= .004). 8/19 (42.2%) in hardware
failure cases required revision surgery, compared to
19/59 (32.2%) in the non-hardware failure cases (p=
.089) The patients with BMI over 30 were 3.5 times
more likely to have hardware failure (95% CI [1.08,
12.22], p = .038). Limb salvage was achieved in all
patients.
Conclusions: The hardware breakage is common following
Charcot hindfoot and midfoot deformity corrections,
highest among combined reconstructions. However,
the clinical and radiological outcomes are still
satisfactory following such complex procedures.
Dedicated durable hardware designed for Charcot
foot reconstructions will potentially reduce this
complication and improve the patient outcomes
further.