Effectiveness of foot orthoses for the prevention of lower limb overuse injuries in naval recruits: a randomised controlled trial.

OBJECTIVES: To evaluate the effectiveness of prefabricated foot orthoses for the prevention of lower limb overuse injuries in naval recruits. METHODS: This study was a participant-blinded and assessor-blinded, parallel-group randomised controlled trial. Three-hundred and six participants aged 17-50 years who undertook 11 weeks of initial defence training at the Royal Australian Navy Recruit School (Cerberus, Australia) were randomised to a control group (flat insoles, n=153) or an intervention group (contoured, prefabricated foot orthoses, n=153). The combined incidence of medial tibial stress syndrome, patellofemoral pain, Achilles tendinopathy and plantar fasciitis/plantar heel pain during the 11-week training period were compared using incidence rate ratios (IRR). Data were analysed using the intention-to-treat principle. RESULTS: Sixty-seven injuries (21.9%) were recorded. The control and intervention group sustained 40 (26.1%) and 27 (17.6%) injuries, respectively (IRR 0.66, 95% CI 0.39 to 1.11, p=0.098). This corresponds to a 34% reduction in risk of developing medial tibial stress syndrome, patellofemoral pain, Achilles tendinopathy or plantar fasciitis/plantar heel for the intervention group compared with the control group. Participants in the prefabricated orthoses group were more likely to report at least one adverse event (20.3% vs 12.4%; relative risk (RR) 1.63, 95% CI 0.96 to 2.76; p=0.068; number needed to harm 13, 95% CI 6 to 253). The most common adverse events were foot blisters (n=20, 6.6%), arch pain (n=10, 3.3%) and shin pain (n=8, 2.6%). CONCLUSION: Prefabricated foot orthoses may be beneficial for reducing the incidence of lower limb injury in naval recruits undertaking defence training. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry: ACTRN12615000024549.

Prevention and treatment of exercise related leg pain in young soldiers; a review of the literature and current practice in the Dutch Armed Forces.

Overuse injuries of the leg are a common problem for young soldiers. This article reviews the literature concerning the prevention and treatment of exercise related leg pain in military settings and presents the latest developments in proposed mechanisms and treatments. Current practice and treatment protocols from the Dutch Armed Forces are reviewed, with an emphasis on the most prevalent conditions of medial tibial stress syndrome and chronic exertional compartment syndrome. The conclusion is that exercise related leg pain in the military is an occupational problem that deserves further study.

Nota clínica. Complicaciones del método Ponseti: Edema de miembro por efecto ventana / Complication of Ponseti’s method: Edema member for windows effect

El pie equinovaro es la deformidad congénita más frecuente, afectando a 1 de cada 1000 recién nacidos vivos. El método más aceptado para su tratamiento es el método Ponseti, que consiste en la utilización de yesos seriados, encaminados a corregir las deformidades asociadas a dicha deformidad. Varias son las complicaciones que pueden aparecer durante el enyesado seriado, aunque la mayoría son banales. En nuestro centro hemos diagnosticado 5 casos de edema de miembro por efecto ventana asociado a este tratamiento. En todos los casos, esta complicación ha aparecido tras retirar el yeso post-tenotomía, previo a la colocación de la férula de abducción. Asociamos esta complicación con la rigidez de las vendas de algodón utilizadas, lo que nos ha llevado a cambiarlas por otras sin trenzado, mucho más distensibles. Actualmente no ha aparecido ningún nuevo caso

The clubfoot is the most common birth defect, affecting 1 in 1000 live births. The most accepted method for treatment is the Ponseti method which consists of serial casting, which corrects all the deformities associated with this deformity. There are several complications that can arise during serial casting, although most are banal. In our center we have diagnosed 5 cases of edema member for windows effect with this treatment. In all cases, this complication has appeared after removal of the post-tenotomy cast, prior to using the abduction brace. We associate this complication with the rigidity of the cotton bandages used, which has led us to change them for other without mesh, much more distensible. Currently, no new caseshave appeared

The management of complications associated with tibial fractures.

Tibial fractures are common and frequently require surgical stabilization. These two factors mean that complications when treating this difficult injury are to be expected. The objectives in the treatment of open tibial shaft fractures are to prevent sepsis, achieve union, and restore function of the limb. However, these goals are often compromised by infection, compartment syndromes, and bone loss associated with many tibial shaft fractures. Recent studies provide a better understanding of the factors involved in the initial care of patients with open tibial fractures and have challenged prior dogmas and practices. An example is studies that define the relationship between the time to débridement of open fractures and subsequent infection. The diagnosis of compartment syndromes continues to be challenging. Careful review of clinical criteria will assist physicians in the early recognition and the management of compartment syndromes. Despite uncomplicated initial care, infections will occur. However, improved knowledge in the basic science of infections, specifically infections about orthopaedic implants, has led to the development of protocols for treatment and obtaining union. Bone loss, a result of either infection or trauma, is one of the most difficult complications to manage. Research regarding bone morphogenesis and the synthesis of multiple compounds has created new options for treating tibial fractures with bone loss.

[The effect of ankle position on intracompartmental pressures of the leg]. / Ayak bilegi pozisyonunun bacakta kompartman içi basinca etkisi.

OBJECTIVES: We investigated differences in the intracompartmental pressures (ICP) of the leg in relation to various positions of the ankle joint in patients with chronic exertional compartment syndrome (CECS). METHODS: The study included 16 patients (10 males, 6 females; mean age 30+/-9 years, range 16 to 48 years) actively involved in various sports. Intracompartmental pressures were monitored with the use of slit catheters connected to a pressure transducer in 28 anterior and 14 deep posterior compartments before and after exercise during the following positions of the ankle joint: relaxed-resting, passive plantar flexion, neutral, and passive dorsiflexion. Alterations in ICP were assessed with reference to that measured in the relaxed-resting position of the ankle. RESULTS: Significant increases in ICP were observed in both anterior and deep posterior compartments during dorsiflexion of the ankle, being 9.1+/-10.6 mmHg (p=0.0001) and 8+/-10.3 mmHg (p=0.001) in the anterior compartment, and 6.4+/-4.4 mmHg (p=0.0001) and 7.2+/-4.3 mmHg (p=0.001) in the deep posterior compartment before and after exercise, respectively. No significant increases were found in other positions of the ankle (p>0.05). While the lowest values of ICP were noted in the relaxed-resting position, plantar flexion of the ankle was associated with decreased ICP pressures. CONCLUSION: Dorsiflexion of the ankle increases ICP significantly in both anterior and deep posterior compartments. The results of this study may have clinical implications for the conservative management of both CECS and tibial fractures.

Well leg compartment syndrome: the debit side of hemilithotomy position.

We describe a case of well leg compartment syndrome following unilateral lithotomy position in a patient undergoing contralateral antegrade intramedullary femoral nailing. Following two-incision four compartment fasciotomy, the patient recovered with no residual defects. We dissuade use of the hemilithotomy position for antegrade femoral nailing procedures in favour of another previously described position, because this predisposes patients to position-associated complications without offering any substantial advantage.

Severe leg compartment syndrome associated with dorsal lithotomy position during radical hysterectomy.

We encountered a female patient with left-leg compartment syndrome; a devastating complication, probably associated with prolonged dorsal lithotomy position during radical hysterectomy using intermittent pneumatic compression. This patient was intensively treated and fortunately recovered. However, leg compartment syndrome is poorly understood by gynecologists. We must always consider the potential risk of this life-threatening complication when patients are placed in the dorsal lithotomy position for a prolonged period during extended surgery using intermittent external compression.

Intramuscular and blood pressures in legs positioned in the hemilithotomy position : clarification of risk factors for well-leg acute compartment syndrome.

BACKGROUND: Acute compartment syndrome has been widely reported in legs positioned in the lithotomy position for prolonged general surgical, urologic, and gynecologic procedures. The orthopaedic literature also contains reports of this complication in legs positioned on a fracture table in the hemilithotomy position. The purpose of this study was to identify the risk factors for development of acute compartment syndrome resulting from this type of leg positioning. METHODS: Eight healthy volunteers were positioned on a fracture table. Intramuscular pressures were continuously measured with a slit catheter in all four compartments of the left leg with the subject supine, in the hemilithotomy position with the calf supported, and in the hemilithotomy position with the heel supported but the calf free. Blood pressure was measured intermittently with use of automated pressure cuffs. RESULTS: Changing from the supine to the calf-supported position significantly increased the intramuscular pressure in the anterior compartment (from 11.6 to 19.4 mm Hg) and in the lateral compartment (from 13.0 to 25.8 mm Hg). Changing from the calf-supported to the heel-supported position significantly decreased intramuscular pressure in the anterior, lateral, and posterior compartments (to 2.8, 3.4, and 1.9 mm Hg, respectively). The mean diastolic blood pressure in the ankle averaged 63.9 mm Hg in the supine position, which significantly decreased to 34.6 mm Hg in the calf-supported position. Changing to the heel-supported position had no significant effect on the diastolic blood pressure in the ankle (mean, 32.8 mm Hg). The mean difference between intramuscular pressure and diastolic blood pressure in the supine position was approximately 50 mm Hg in each of the four compartments. This mean difference significantly decreased to <20 mm Hg in the calf-supported position and then, when the leg was moved into the heel-supported position, significantly increased to approximately 30 mm Hg in all compartments. CONCLUSIONS: The combination of increased intramuscular pressure due to external compression from the calf support and decreased perfusion pressure due to the elevated position causes a significant decrease in the difference between the diastolic blood pressure and the intramuscular pressure when the leg is placed in the hemilithotomy position in a well-leg holder on a fracture table. Combined with a prolonged surgical time, this position may cause an acute compartment syndrome of the well leg. Leaving the calf free, instead of using a standard well-leg holder, increases the difference between the diastolic blood pressure and the intramuscular pressure and may decrease the risk of acute compartment syndrome.

Well-leg compartment pressures during hemilithotomy position for fracture fixation.

OBJECTIVE: To evaluate the relationship between the well-leg compartment pressures and time during hemilithotomy position for fracture fixation. DESIGN: Prospective. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Ten patients who underwent intramedullary nailing of a fractured femur in the hemilithotomy position (with a well-leg holder). INTERVENTION: Continuous pressure monitoring was achieved with in-dwelling slit catheters inserted into the calf compartments of the well leg. Baseline measurements were obtained in the supine position. After the leg was placed in the hemilithotomy position, compartment pressures were monitored throughout surgery. MAIN OUTCOME MEASUREMENTS: Calf compartment pressures at baseline, during hemilithotomy position, and post-hemilithotomy were compared. The association between body mass index and compartment pressure was analyzed. RESULTS: A consistent pattern was observed between compartment pressures and time. The curve was that of a step function in which the pressure increased as soon as the leg was placed in the well-leg holder and remained elevated until the leg was taken down. The pressure jumped from a baseline of 9.2 to 27.3 millimeters of mercury (mm Hg) (p<0.0001). While in the hemilithotomy position, the leg pressure trended slightly upward. Once the leg was taken down, the pressure immediately returned to a near-baseline level of 8.1 mm Hg (p<0.0001). A significant correlation was also found between the body mass index and leg pressure (R2 = 0.713; F = 0.002). CONCLUSIONS: The use of the well-leg holder to maintain hemilithotomy position increases the calf compartment pressures dramatically and significantly. Therefore, we recommend avoiding this position for fracture fixation in at-risk patients.

Selective type III phosphodiesterase inhibition prevents elevated compartment pressure after ischemia/reperfusion injury.

BACKGROUND: A new synthetic cyclic adenosine monophosphate phosphodiesterase inhibitor, cilostazol, has been shown to inhibit platelet aggregation and act synergistically with endogenous prostaglandin I2 to enhance smooth-muscle cell vasodilitation. The effect of cilostazol in ischemia/reperfusion injury-induced compartment syndrome was investigated. METHODS: Sixteen rabbits underwent femoral artery occlusion after ligation of branches from the terminal aorta to the femoral artery. After 7 hours of ischemia, reperfusion was established with heparinized polyethylene shunts. Experimental animals (n = 8) received cilostazol (3.0 mg/kg) and control animals (n = 8) received normal saline as an intravenous infusion 10 minutes before shunt placement. During reperfusion, anterior compartment pressure was continuously monitored in the left lower extremity, and femoral artery blood flow was measured by laser Doppler fluorometry. To quantitate skeletal muscle oxidative metabolism and viability, triphenyltetrazolium chloride (TTC) reduction (micrograms of TTC per milligram of protein) of tibialis anterior muscle from the right lower extremity was measured at femoral artery occlusion, 7 hours of ischemia, and 2 hours of reperfusion. To assess tissue edema, dry/wet weight ratios were also determined at these intervals. Data were expressed as means +/- SE. Comparisons within groups were performed by analysis of variance, and comparisons between groups with two-tailed unpaired t tests. RESULTS: At 2 hours of reperfusion, the difference between controls and cilostazol-treated animals was extremely significant (p = 0.0008). Preischemia and 2-hour reperfusion TTC and dry/wet weight ratios were not significantly different within or between experimental groups, nor was femoral artery blood flow during reperfusion. CONCLUSION: Cilostazol inhibits the increase in compartment pressure central to the development of the compartment syndrome. The mechanism appears to be independent of altered tissue permeability or oxidative metabolism.

Effects of limb elevation on abnormally increased intramuscular pressure, blood perfusion pressure, and foot sensation: an experimental study in humans.

OBJECTIVES: To study the effects of limb elevation on abnormally increased intramuscular pressure (IMP) and blood perfusion pressure in the anterior compartment of the leg. DESIGN: An experimental cross-over design. The test leg was elevated and the control leg was kept at heart level. PARTICIPANTS: Eight healthy subjects with a mean age of twenty-nine years. INTERVENTION: IMP was measured in the anterior compartment of the leg, and blood pressures were taken in the left arm and both legs. Four variables were recorded (with or without venous stasis, with or without plaster cast). All measurements were made simultaneously in both legs. RESULTS: When the leg was obstructed by venous stasis and elevated to between thirty-three and thirty-five centimeters, IMP decreased from 16.5 to 9.8 millimeters of mercury. When venous stasis was simulated in a level casted leg, the IMP was thirty-eight (SD = 6.4) millimeters of mercury but showed only a slight decline to thirty-five (SD = 7.8) millimeters of mercury after the leg was elevated. Blood perfusion pressure fell significantly once the leg was elevated, decreasing 53 percent from forty-seven (SD = 7.8) to twenty-five (SD = 8.0) millimeters of mercury (p < 0.001). All subjects experienced loss of foot sensation in the elevated limb. CONCLUSION: In those cases in which venous stasis increased IMP levels in the anterior compartment of the leg, elevating the limb produced a 40 percent reduction in IMP. However, limb elevation did not significantly reduce increased IMP levels when the venous stasis occurred in a casted leg. Therefore, we believe casted legs in which abnormally increased IMP is attributable to venous stasis should not be elevated above heart level because elevation induces low perfusion pressure and sensory dysfunction.

Prevention of compartment syndrome associated with dorsal lithotomy position.

There is a clear association between the dorsal lithotomy position and the development of a postoperative compartment syndrome. Compartment syndrome occurs when elevated pressure in an osteofascial compartment compromises local perfusion and often results in neurovascular damage and permanent disability. Surgeons must recognize this association and provide appropriate preventative measures, have a high index of suspicion in all patients, and be prepared to make an early diagnosis when it is encountered. We will report four cases we encountered, discuss the etiology, analyze the literature, and propose a modification on patient positioning that has minimized the incidence of compartment syndrome at our institution. A variety of intraoperative events, including hypotension, hypoxemia, leg elevation, hip and knee flexion, direct pressure, and compressive bandages may all contribute to compartmental ischemia. Ischemia is followed by reperfusion, capillary leakage from the ischemic tissue, and a further increase in tissue edema. Increased edema causes further embarrassment of perfusion and perpetuation of the cycle, ultimately resulting in neuromuscular compromise secondary to ischemia. To prevent this destructive cycle, emphasis must be placed on maintaining a high index of suspicion in all patients, minimizing leg elevation, and on the importance of early diagnosis and intervention.

Effect of ankle position and a plaster cast on intramuscular pressure in the human leg.

Intramuscular pressure was measured with transducer-tipped catheters that had been inserted into the anterior and deep posterior compartments of the leg in seven healthy adults. Intramuscular pressure increased three to sevenfold (depending on the position of the ankle) in both compartments after the application of a plaster cast from the proximal part of the thigh to the malleoli. While the cast was in place, the baseline intramuscular pressure was elevated by the inflation of a tourniquet, which was located on the proximal part of the thigh, to a pressure of sixty millimeters of mercury (8.00 kilopascals). The intramuscular pressure in both the anterior and the deep posterior compartments was found to be lowest when the ankle joint was between the neutral and the resting positions (between 0 and 37 degrees of flexion). After the cast was bivalved and the opening on each side was spread approximately one-half centimeter, there was a significant decrease in intramuscular pressure of 47 per cent in the anterior compartment and of 33 per cent in the deep posterior compartment (p < 0.05 for both).

Prophylactic fasciotomy of the legs following acute arterial occlusion procedures.

During the 3-year period, 1983-86, 194 procedures for acute arterial occlusion were performed in our Clinic. In 43 cases following revascularization procedures, decompression fasciotomy of the leg for a developed or impending compartment syndrome was performed. Of these, three fasciotomies were done as a prophylactic procedure, before the development of the syndrome. Adequate and early fasciotomy should be considered by the vascular surgeon in every case of embolectomy when the ischemic time is greater than 6 hours, when the patient is young without sufficient collateral circulation, the history of acute arterial occlusion is precipitous, the patient is hypotensive and the back-flow is inadequate intra-operatively, despite the passage of the Fogarty's catheter down to the malleolus. Skin closure after fasciotomy has to be done early, mainly with approximation of the skin edges, or to cover early the exposed viable muscles with a free split-thickness autogenous skin graft. This was done in our series between the 8th and 14th postoperative days. In the case of muscle necrosis of the anterior compartment, skin coverage of the cavity has to be done later, after 2-3 weeks, as in some of our patients.

Ankle and knee position as a factor modifying intracompartmental pressure in the human leg.

The objective of this study was to examine the effect of position of the knee and ankle on intracompartmental pressures in the leg. Slit catheters were introduced bilaterally into all four muscle compartments of the lower extremities of six healthy volunteers. Intracompartmental pressures were monitored with the catheters while the ankle joint was passively held in full dorsiflexion, full plantar flexion, or neutral with the knee flexed 90 or 10 degrees or fully extended. Statistical analysis revealed that intracompartmental pressure increased significantly in all four compartments when the ankle was passively dorsiflexed. Pressure in the superficial posterior and lateral compartments was dependent on knee position and in the deep posterior and anterior compartments it was independent of knee position. In addition, pressure in the deep posterior compartment decreased significantly when the ankle was placed in full plantar flexion, and that finding was independent of knee position. Anterior compartment pressure was not significantly elevated by full passive plantar flexion of the ankle.