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Early active motion versus immobilization after tendon transfer for foot drop deformity: a randomized clinical trial.

Rath S, Schreuders TA, Stam HJ, Hovius SE, Selles RW - Clin. Orthop. Relat. Res. (2010)

Bottom Line: Several recent studies suggest early mobilization does not increase tendon pullout.Rehabilitation time in the mobilized group was reduced by an average of 15 days.See Guidelines for Authors for a complete description of levels of evidence.

View Article: PubMed Central - PubMed

Affiliation: LEPRA Funded Leprosy Reconstructive Surgery Unit, HOINA, Muniguda, Orissa, India. handsurgery.rath@gmail.com

ABSTRACT

Background: Immobilization after tendon transfers has been the conventional postoperative management. Several recent studies suggest early mobilization does not increase tendon pullout.

Questions/purposes: To confirm those studies we determined whether when compared with immobilization early active mobilization after a tendon transfer for foot-drop correction would (1) have a similar low rate of tendon insertion pullout, (2) reduce rehabilitation time, and (3) result in similar functional outcomes (active ankle dorsiflexion, plantar flexion, ROM, walking ability, Stanmore score, and resolution of functional problems.

Methods: We randomized 24 patients with surgically corrected foot-drop deformities to postoperative treatment with early mobilization with active motion at 5 days (n = 13) or 4 weeks of immobilization with active motion at 29 days (n = 11). In both groups, the tibialis posterior tendon was transferred to the extensor hallucis longus and extensors digitorum communis for foot-drop correction. Rehabilitation time was defined as the time from surgery until discharge from rehabilitation with independent walking. The minimum followup was 16 months (mean, 19 months; range, 16-38 months) in both groups.

Results: We observed no case of tendon pullout in either group. Rehabilitation time in the mobilized group was reduced by an average of 15 days. The various functional outcomes were similar in the two groups.

Conclusion: In patients with Hansen's disease, an early active mobilization protocol for foot-drop correction has no added risk of tendon pullout and provides similar functional outcomes compared with immobilization. Early mobilization had the advantage of earlier restoration of independent walking.

Level of evidence: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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Related in: MedlinePlus

A CONSORT flow diagram illustrates the design of the RCT comparing early mobilization versus immobilization after tendon transfer for foot-drop.
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Fig1: A CONSORT flow diagram illustrates the design of the RCT comparing early mobilization versus immobilization after tendon transfer for foot-drop.

Mentions: We designed a randomized control trial to assess early mobilization versus postoperative immobilization in patients with Hansen’s disease having a tendon transfer for foot-drop correction. From July 2005 until June 2006 we performed a tendon transfer in 39 patients with Hansen’s disease with irreversible common peroneal nerve paralysis of greater than a year in duration. The diagnosis and treatment of the disease occurred at the field level by trained medical staff of the National Leprosy Eradication Programme. The neurologic deficit was documented by the physiotherapist using the manual muscle strength test (MMST) grading [2]. All patients had completed multidrug therapy for Hansen’s disease and the muscle strength of the ankle dorsiflexors was MMST Grade 0. We excluded nine patients with clawed toes having additional surgery, active neuropathic plantar ulcers, absorption of toes, and Charcot’s arthropathy of the feet and ankles (Fig. 1). Six patients were not able to return for repeat followups and therefore were excluded (Fig. 1). These exclusions left 24 patients for the RCT; these patients were randomized postoperatively into one of two groups: those receiving early mobilization (mobilized group) or those receiving 4 weeks of immobilization (immobilized group). Randomization was performed using unmarked sealed opaque envelopes that were mixed in a box. A person not involved in the trial assigned the patients to the groups by opening an envelope picked at random from the box after completion of surgery and wound closure to avoid any influence of group allocation on surgical procedures. Thirteen patients were allocated to the mobilized group and 11 to the immobilized group. The patients in both groups were similar in age, gender, side of involvement, and duration of paralysis (Table 1). For a power analysis, we used data for rehabilitation time from a previous prospective cohort study [8] of patients using early active mobilization (rehabilitation time, 44 ± 8 days) and an historical cohort of patients who received immobilization (rehabilitation time, 57 ± 8 days). We calculated that with a 10-day difference in rehabilitation time between groups and a group size of 10 patients we would have a power of 97%.Fig. 1


Early active motion versus immobilization after tendon transfer for foot drop deformity: a randomized clinical trial.

Rath S, Schreuders TA, Stam HJ, Hovius SE, Selles RW - Clin. Orthop. Relat. Res. (2010)

A CONSORT flow diagram illustrates the design of the RCT comparing early mobilization versus immobilization after tendon transfer for foot-drop.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2914290&req=5

Fig1: A CONSORT flow diagram illustrates the design of the RCT comparing early mobilization versus immobilization after tendon transfer for foot-drop.
Mentions: We designed a randomized control trial to assess early mobilization versus postoperative immobilization in patients with Hansen’s disease having a tendon transfer for foot-drop correction. From July 2005 until June 2006 we performed a tendon transfer in 39 patients with Hansen’s disease with irreversible common peroneal nerve paralysis of greater than a year in duration. The diagnosis and treatment of the disease occurred at the field level by trained medical staff of the National Leprosy Eradication Programme. The neurologic deficit was documented by the physiotherapist using the manual muscle strength test (MMST) grading [2]. All patients had completed multidrug therapy for Hansen’s disease and the muscle strength of the ankle dorsiflexors was MMST Grade 0. We excluded nine patients with clawed toes having additional surgery, active neuropathic plantar ulcers, absorption of toes, and Charcot’s arthropathy of the feet and ankles (Fig. 1). Six patients were not able to return for repeat followups and therefore were excluded (Fig. 1). These exclusions left 24 patients for the RCT; these patients were randomized postoperatively into one of two groups: those receiving early mobilization (mobilized group) or those receiving 4 weeks of immobilization (immobilized group). Randomization was performed using unmarked sealed opaque envelopes that were mixed in a box. A person not involved in the trial assigned the patients to the groups by opening an envelope picked at random from the box after completion of surgery and wound closure to avoid any influence of group allocation on surgical procedures. Thirteen patients were allocated to the mobilized group and 11 to the immobilized group. The patients in both groups were similar in age, gender, side of involvement, and duration of paralysis (Table 1). For a power analysis, we used data for rehabilitation time from a previous prospective cohort study [8] of patients using early active mobilization (rehabilitation time, 44 ± 8 days) and an historical cohort of patients who received immobilization (rehabilitation time, 57 ± 8 days). We calculated that with a 10-day difference in rehabilitation time between groups and a group size of 10 patients we would have a power of 97%.Fig. 1

Bottom Line: Several recent studies suggest early mobilization does not increase tendon pullout.Rehabilitation time in the mobilized group was reduced by an average of 15 days.See Guidelines for Authors for a complete description of levels of evidence.

View Article: PubMed Central - PubMed

Affiliation: LEPRA Funded Leprosy Reconstructive Surgery Unit, HOINA, Muniguda, Orissa, India. handsurgery.rath@gmail.com

ABSTRACT

Background: Immobilization after tendon transfers has been the conventional postoperative management. Several recent studies suggest early mobilization does not increase tendon pullout.

Questions/purposes: To confirm those studies we determined whether when compared with immobilization early active mobilization after a tendon transfer for foot-drop correction would (1) have a similar low rate of tendon insertion pullout, (2) reduce rehabilitation time, and (3) result in similar functional outcomes (active ankle dorsiflexion, plantar flexion, ROM, walking ability, Stanmore score, and resolution of functional problems.

Methods: We randomized 24 patients with surgically corrected foot-drop deformities to postoperative treatment with early mobilization with active motion at 5 days (n = 13) or 4 weeks of immobilization with active motion at 29 days (n = 11). In both groups, the tibialis posterior tendon was transferred to the extensor hallucis longus and extensors digitorum communis for foot-drop correction. Rehabilitation time was defined as the time from surgery until discharge from rehabilitation with independent walking. The minimum followup was 16 months (mean, 19 months; range, 16-38 months) in both groups.

Results: We observed no case of tendon pullout in either group. Rehabilitation time in the mobilized group was reduced by an average of 15 days. The various functional outcomes were similar in the two groups.

Conclusion: In patients with Hansen's disease, an early active mobilization protocol for foot-drop correction has no added risk of tendon pullout and provides similar functional outcomes compared with immobilization. Early mobilization had the advantage of earlier restoration of independent walking.

Level of evidence: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Show MeSH
Related in: MedlinePlus