The Utility of Dynamic Movement Orthoses in the Management of Complex Regional Pain Syndrome—A Case Series

ABSTRACT Complex regional pain syndrome (CRPS) is a relatively rare, but debilitating condition that may occur after limb or peripheral nerve trauma. Typical symptoms of CRPS include swelling, allodynia, hyperalgesia, and skin temperature changes. Although a variety of pharmacological and non-pharmacological approaches are commonly used in caring for individuals with CRPS, they are frequently ineffective and often associated with side effects and/or additional risks. Previously, elastomeric orthotic garments have been shown to decrease neuropathic pain, reduce edema, and increase proprioception, but no previous reports have described their use in treating CRPS. Accordingly, this case series describes our experiences using a Lycra-based, custom-fabricated Dynamic Movement Orthosis (DMO) as a novel treatment to reduce the symptoms of CRPS and promote function. Four patients were included in this case series, all of whom had very different causes for their CRPS, including a combat-related gunshot injury resulting in multiple foot fractures with a partial nerve injury, a post-metatarsophalangeal fusion, an L5 radiculopathy, and a case of post-lower leg fasciotomies. These four patients all reported subjective improvement in their pain, function, and exercise tolerance in association with their DMO use. All patients demonstrated reduced use of analgesic medications. The pre- and post-DMO lower extremity functional scale showed clinically significant improvement in the two patients for which it was obtained.

Kirschner Wire as a Reference Marker for the Positioning of a Syndesmotic Screw: a Radiological Study and Clinical Application

Background: Without a reliable and static reference, the rate of eccentrically positioned distal syndesmotic screw is very high. This article describes an additional method to improve surgeons’ ability to ideally place this screw. The purposes of our study were (1) to determine if an ideal space at 2.5 cm proximal to the plafond existed between the tibia and fibula for the placement of a Kirschner (K) wire and (2) to detect if it could act as a reliable and static fibular incisura plane reference. Methods: Computed tomography (CT) scans of 42 uninjured adult ankles with foot fractures were analysed to measure the tibiofibular vertical distance (TFVD) at 2.5 cm proximal to the plafond on transverse images. TFVD was defined as the distance between two lines: Line 1 was tangent to the fibular incisura, and Line 2 was parallel to Line 1 along the medial fibula. Patients were divided into four groups according to our TFVD data: 0–1, 1–2, 2–3, and 3–4 mm, and the number of patients in each group was counted. We assessed 23 patients who underwent syndesmotic screw fixation for ankle fractures. Comparison of the angle between the anatomic axis of the syndesmosis and screw axis (AAS) was performed between patients using conventional method (11 patients) and with K-wire marker (12 patients). Results: TFVD measured 2.23 ± 1.01 mm at 2.5 cm proximal to the plafond. TFVD occurred at 25% of the distance from 2 to 3 mm in 47.6% of patients. This new technique decreased the deformation of AAS by 75%, from 13.06 ± 2.55° to 4.28 ± 1.72°, in the conventional group.Conclusions: Placing a 1.6-mm K-wire in the syndesmosis at 2.5 cm proximal to the tibial plafond is easy because of emerging TFVDs. Compared to the conventional method, this new technique increased the accuracy of syndesmotic screw placement by up to 75 percent. Therefore, K-wire could be used as a reliable and static intraoperative reference of the fibular incisura plane through which surgeons can accurately place a screw trajectory.

Kirschner Wire as a Reference Marker for the Positioning of a Syndesmotic Screw: A Radiological Study

Background: Without a reliable and static reference, the rate of eccentrically positioned distal syndesmotic screw trajectories is very high. Meanwhile, a malpositioned screw may result in poor outcomes and early osteoarthritis. As such, this article describes an additional method to improve surgeons’ ability to ideally place a screw trajectory. The purposes of our study were (1) to determine if an ideal space at 2.5 cm proximal to the plafond existed between the tibia and fibula for the placement of a Kirschner (K) wire and (2) to detect if it could act as a reliable and static fibular incisura plane reference.Methods: Computed tomography scans of 42 uninjured adult ankles with foot fractures were analysed to measure the tibiofibular vertical distance (TFVD) at 2.5 cm proximal to the tibial plafond on cross-sectional images. The TFVD was defined as the distance between two lines: Line 1 was tangent to the fibular incisura, and Line 2 was parallel to Line 1 along the medial border of the fibula. Patients were divided into 4 groups according to our TFVD data: 0–1, 1–2, 2–3, and 3–4 mm, and the number of patients in each group was counted.Results: The TFVD measured 2.23±1.01 mm (mean ± standard deviation) at 2.5 cm proximal to the plafond. According to our grouping, TFVD occurred at 25% of the distance from 2 to 3 mm in 47.6% of patients. Conclusions: Placing a 1.6-mm K-wire in the syndesmosis at 2.5 cm proximal to the tibial plafond is easy because of emerging TFVDs. The K-wire’s path is restricted to the anterior and posterior borders of the fibular incisura pass because of the limitation of the medial border of the fibula and syndesmosis tendon. Therefore, K-wire could be used as a reliable and static intraoperative reference of the fibular incisura plane through which surgeons can accurately place a screw trajectory.

Incidence and Hematological Biomarkers Associated With Preoperative Deep Venous Thrombosis Following Foot Fractures

Background: This study was designed to investigate the incidence and hematological biomarker levels that are associated with deep venous thrombosis (DVT) following closed foot fractures (except calcaneal fractures). Methods: A retrospective analysis of data on patients presenting with closed foot fractures (excluding the calcaneus) between October 2014 and December 2018 was conducted. Duplex ultrasonography was used to screen preoperative DVT of bilateral lower extremities. Data on demographics, comorbidities, types of fracture, and laboratory biomarkers at admission were collected. Univariate analyses and multivariate logistic regression analyses were carried out to determine the independent risk factors associated with DVT. Results: A total of 537 patients were included, among whom 28 patients had preoperative DVTs, indicating a crude incidence rate of 5.2%. In isolated closed foot fractures, DVT occurred in 12 (2.9%) out of 410 patients, while in patients with concurrent fracture in other locations, 16 (12.6%) out of 127 patients developed DVT. The average interval between fracture occurrence and diagnosis of DVT was 4.2 days (median, 2 days), ranging from 0 to 17 days. Twenty-four patients (85.7%) developed DVT in the injured extremity, 3 (10.7%) in the uninjured extremity, and 1 (3.5%) in bilateral extremities. Seven risk factors were identified to be associated with DVT, including alcohol consumption, concomitant other fractures, platelet distribution width (PDW) <12%, high-density lipoprotein cholesterol (HDL-C) <1.1mmol/L, serum alkaline phosphatase (ALP) >100 U/L, serum sodium concentration (Na+) <135 mmol/L, and D-dimer >0.5 mg/L. Conclusion: Being aware of the prevalence of DVT in closed foot fractures can help physicians to carry out the overall assessment, risk stratification, and individual prevention programs. Level of Evidence: Level III, a prospective cohort study.