Beynnon BD, Renström PA, Haugh L, Uh BS, Barker H. A prospective, randomized clinical investigation of the treatment of first-time ankle sprains. Am J Sports Med. 2006;34:1401-12.
This well-designed prospective, randomized clinical investigation analyzed the short-term outcomes of first-time clinical grade-I, II, and III inversion sprains of the lateral ligaments of the ankle using different treatment modalities. The primary objective of the study was to compare early, controlled mobilization with use of different types of external support known as functional treatment (Air-Stirrup brace, elastic wrap, and Air-Stirrup brace combined with an elastic wrap) with immobilization (walking cast) for patients with first-time inversion ankle sprains. The results at six months of follow-up corresponded with the findings of previous studies in that the type of treatment that was employed appeared to have no effect on eventual restoration of function or the frequency of reinjury. The evidence suggested that, in the long term, lateral ankle sprains heal with excellent or good outcomes, irrespective of the treatment received. However, the short-term results provided evidence supporting the treatment of first-time grade-I and II inversion ankle sprains with an Air-Stirrup brace combined with an elastic wrap. This treatment provided earlier return to pre-injury function compared with treatment with the Air-Stirrup brace alone, an elastic wrap alone, or a walking cast for ten days followed by the use of an elastic wrap. In the first-time grade-III sprain group, there were insufficient numbers to compare different types of functional treatment.
Jones MH, Amendola AS. Acute treatment of inversion ankle sprains: immobilization versus functional treatment. Clin Orthop Relat Res. 2007;455:169-72.
The authors used PubMed to perform a systematic review of the literature in order to identify randomized, controlled trials in which immobilization was compared with some form of functional treatment for the acute treatment of inversion ankle sprains. Nine studies were ultimately identified for review. The outcomes of interest were whether any differences existed in the time to return to the pre-injury level of activity, the level of patient satisfaction, the presence of subjective instability, and the rate of re-injury. Significant variation existed in the reviewed articles between the type and duration of immobilization, the mode of functional treatment employed, the number of subjects included, and outcome measures. However, there were trends toward earlier return to pre-injury activity in patients receiving early functional treatment. No substantial difference was found between the treatment groups in terms of recurrent instability and re-injury, whereas slightly greater satisfaction was reported by patients managed with immobilization. Additional studies need to be performed to better evaluate the optimum method of treatment.
Dalton JD Jr, Schweinle JE. Randomized controlled noninferiority trial to compare extended release acetaminophen and ibuprofen for the treatment of ankle sprains. Ann Emerg Med. 2006;48:615-23.
Lateral ankle sprains are one of the most common musculoskeletal injuries, and treatment of the associated acute pain and swelling is of important therapeutic interest. Previous double-blinded controlled trials have established the efficacy of ibuprofen as compared with placebo for treatment of the pain and swelling associated with lateral ankle sprains. In this multi-center, randomized, double-blinded, parallel-group study, the efficacy of extended-release acetaminophen (3900 mg daily) was compared with that of ibuprofen (1200 mg daily) for the treatment of pain associated with grade-I or II lateral ankle sprains during a nine-day study period. The study utilized a noninferiority design to demonstrate that this dose of acetaminophen is not inferior to ibuprofen at a dosage of 1200 mg daily for the treatment of lateral ankle sprains. Thus, as ibuprofen has been previously shown to be more efficacious than placebo for the treatment of lateral ankle sprains, this study established that acetaminophen can produce similar effects. Therefore, extended-release acetaminophen can be used to manage acute pain associated with grade-I or II lateral ankle sprains in a manner comparable with that of ibuprofen.
Middleton F, Coakes J, Umarji S, Palmer S, Venn R, Panayiotou S. The efficacy of intra-articular bupivacaine for relief of pain following arthroscopy of the ankle. J Bone Joint Surg Br. 2006;88:1603-5.
The intra-articular injection of bupivacaine for the control of postoperative pain has been proved to be safe and effective following arthroscopy of the knee but not arthroscopy of the ankle. In this prospective, randomized, double-blind clinical trial, the authors compared intra-articular injection of 20 mL of 0.5% bupivacaine to injection of 20 mL of normal saline solution. The analgesic effect was assessed with use of a visual analog scale as well as by measuring the amount of additional analgesic medication required in the recovery room and after discharge. Significantly lower visual analog scores (indicating less pain) on the day of operation at thirty minutes, sixty minutes, and 120 minutes after the procedure and less intravenous tramadol use for postoperative analgesia was noted in the bupivacaine group. A trend toward lower visual analog scale scores at twelve hours following arthroscopy was noted, whereas no significant difference occurred on the day after the operation. These results suggest that intra-articular injection of 20 mL of 0.5% bupivacaine significantly reduces the initial levels of pain and the requirement for analgesics after ankle arthroscopy.
de Vries JS, Krips R, Sierevelt IN, Blankevoort L. Interventions for treating chronic ankle instability. Cochrane Database Syst Rev. 2006;4:CD004124.
The authors reviewed seven randomized trials of interventions for chronic ankle instability involving 308 patients in order to compare different nonoperative and operative treatments. No definitive conclusions could be drawn because of a lack of significance and poor methodological quality. Patient outcomes in terms of the time to return to work and sports were found to be superior following functional rehabilitation as compared with immobilization. Therefore, the authors recommended functional postoperative rehabilitation for patients with chronic ankle instability, emphasizing early mobilization of the ankle joint instead of six weeks of immobilization.
Kerkhoffs GM, Handoll HH, de Bie R, Rowe BH, Struijs PA. Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. Cochrane Database Syst Rev. 2007;2:CD000380.
The authors reviewed twenty randomized or quasi-randomized trials involving a total of 2562 patients to compare operative and nonoperative methods for the treatment of acute injuries of the lateral ligament complex of the ankle. Data for pooling of individual outcomes were available for only twelve trials and <60% of participants. There was insufficient evidence from the pooled data to determine the relative effectiveness of operative and nonoperative treatment of acute injuries of lateral ligaments of the ankle. There was some evidence of stiffness and restrictions in ankle mobility as well as a longer time to return to work associated with surgery. Until adequately powered, high-quality, and appropriately reported randomized trials supporting either treatment are done, the best current option remains nonoperative treatment with close follow-up to identify patients with persistent symptoms.
Kangas J, Pajala A, Ohtonen P, Leppilahti J. Achilles tendon elongation after rupture repair: a randomized comparison of 2 postoperative regimens. Am J Sports Med. 2007;35:59-64.
This randomized clinical trial evaluated the effect of contrasting postoperative regimens after surgical repair of Achilles tendon ruptures. Intratendinous metallic markers were placed on both sides of the ruptured Achilles tendon ends after a standard Achilles tendon rupture repair. Patients were then randomized into postoperative treatment with either a below-the-knee dorsal rigid plaster splint that allowed active plantar flexion but restricted dorsiflexion to neutral or a below-the-knee plaster splint with the ankle in a neutral position. Patients were followed functionally and with standardized radiographs to reproducibly measure and accurately track postoperative elongation of the repaired tendon. Significant Achilles tendon elongation occurred in both postoperative regimens, although it was somewhat less in the early motion group. Elongation increased up to six weeks after repair in both groups, at which time the Achilles tendon preserved its length or even shortened slightly in the early motion group. A significant correlation was also found between Achilles tendon elongation and functional outcome. Patients with less shortening achieved significantly better clinical outcomes. These results suggest that protected functional rehabilitation after Achilles tendon repair may reduce postoperative tendon elongation and thereby improve clinical outcomes.
Gobbi A, Francisco RA, Lubowitz JH, Allegra F, Canata G. Osteochondral lesions of the talus: randomized controlled trial comparing chondroplasty, microfracture, and osteochondral autograft transplantation. Arthroscopy. 2006;22:1085-92.
Arthroscopic chondroplasty, microfracture, and osteochondral autologous transplantation are common surgical techniques for the treatment of osteochondral lesions of the talus. However, scarce evidence exists providing guidelines to aid the surgeon in the selection of technique. This prospective randomized study compared outcomes following these surgical modalities for the treatment of arthroscopically accessible anterior and lateral osteochondral lesions of the talus. The results demonstrated no difference in outcomes at the time of the two-year follow-up between chondroplasty, microfracture, and osteochondral autologous transplantation. The only significant difference between treatment groups was increased postoperative pain at twenty-four hours in patients receiving osteochondral autologous transplantation. On the basis of these results, chondroplasty and microfracture may be the preferred treatment for arthroscopically accessible osteochondral lesions of the talus on the basis of comparable outcomes, lower postoperative pain, and the more extensive nature of osteochondral autologous transplantation.
Piaggesi A, Macchiarini S, Rizzo L, Palumbo F, Tedeschi A, Nobili LA, Leporati E, Scire V, Teobaldi I, Del Prato S. An off-the-shelf instant contact casting device for the management of diabetic foot ulcers: a randomized prospective trial versus traditional fiberglass cast. Diabetes Care. 2007;30: 586-90.
Total contact casting is the gold standard for the treatment of superficial neuropathic diabetic foot ulcers, yet it remains an expensive, time-demanding, and resource-consuming treatment option. The authors of this prospective randomized clinical trial sought to determine the efficacy of an off-the-shelf off-loading walker device (the Optima Diab walker). The device is designed to be irremovable by the patient but can be removed at clinical visits by cutting a securing plastic lace with a specific tool. The purpose of the study was to find a more practical, less expensive, safe, and comparably effective alternative to total contact casting. Two groups of patients with superficial diabetic foot ulcers were randomized to receive total contact casting or the Optima Diab walker. The Optima Diab walker was found to be significantly less expensive, required significantly less time to apply and remove, and resulted in higher patient satisfaction scores. Additionally, in both treatment groups, the ulcers healed at an average of approximately 6.5 weeks with a comparable number of minor adverse events. The Optima Diab walker may present a reasonable alternative to total contact casting for the treatment of superficial neuropathic diabetic foot ulcers on the basis of cost reduction, ease of application, lower resource expenditure, and comparable efficacy.