What is the preferred immobilization method, short leg cast or posterior splint, for a patient status post subtalar arthrodesis and calcaneus hardware removal?

Immobilization After Subtalar Arthrodesis and Calcaneus Hardware Removal

Functional support with a removable ankle brace is preferred over a short leg cast for patients after subtalar arthrodesis and calcaneus hardware removal, as it provides better outcomes for mobility, healing, and return to function.

Rationale for Functional Support vs. Rigid Immobilization

• Functional support for 4-6 weeks is preferred over rigid immobilization for lower extremity injuries, as it allows controlled loading of damaged tissues while providing protection 1
• A minimum of 4 weeks in a lower leg cast results in less optimal outcomes compared with functional support and exercise strategies (22 RCTs, n=2304) 1
• Functional treatment with ankle braces shows greater effects compared with other types of functional support (level 2 evidence) 1

Benefits of Functional Support

• Functional support allows for:

  • Earlier return to work (RR 5.75,95% CI 1.01 to 32.71) 1
  • Better patient satisfaction (RR 4.25,95% CI 1.12 to 16.09) 1
  • Earlier return to sports activities (RR 1.86,95% CI 1.22 to 2.86) 1
  • Fewer days until return to work (MD 8.23 days, 95% CI 6.31 to 10.16) 1

• Removable rigid dressings (RRDs) have been shown to:

  • Reduce acute hospital length of stay (15.9 days vs. 8.7 days, p < .001) 1
  • Accelerate limb volume reduction rates in the first two weeks compared to soft dressings 1
  • Lead to earlier and more frequent use of prosthesis 1

Short-Term Immobilization Considerations

• A short period (<10 days) of immobilization with a plaster cast or rigid support can be of added value in decreasing pain and edema immediately post-operatively 1
• After this initial period, transition to functional treatment should be implemented 1
• Patients treated with functional support have significantly fewer complications such as skin irritations (RR 0.11,95% CI 0.01 to 0.86) compared to rigid immobilization 1

Specific Recommendations for Subtalar Arthrodesis

• For subtalar arthrodesis after calcaneus fractures, functional support facilitates frontal plane deformity correction while allowing for wound inspection 2
• In patients who have undergone subtalar fusion, maintaining alignment while allowing controlled movement is critical for successful outcomes 3, 4
• Functional bracing after subtalar arthrodesis allows for:
  • Better wound monitoring and care 2
  • Earlier initiation of exercise therapy, which is associated with quicker recovery and enhanced outcomes (level 1 evidence) 1
  • Reduced risk of complications such as joint stiffness and impaired mobility 4

Implementation Protocol

1. Consider short-term (<10 days) rigid immobilization immediately post-operatively to control pain and initial swelling 1
2. Transition to a removable functional brace for 4-6 weeks 1
3. Begin appropriate exercise therapy as early as possible to improve outcomes 1
4. Monitor for proper healing before advancing weight-bearing status 5

Common Pitfalls to Avoid

• Prolonged immobilization (>4 weeks) in a rigid cast can lead to:
  • Ankle stiffness and impaired mobility 1
  • Delayed return to work and activities 1
  • Muscle atrophy and deconditioning 1
• Inadequate support can lead to loss of alignment or protection of the surgical site 5
• Failure to initiate early exercise therapy may result in poorer functional outcomes 1

By implementing functional support with a removable ankle brace rather than a short leg cast after subtalar arthrodesis and calcaneus hardware removal, patients will likely experience better outcomes including faster healing, earlier return to function, and fewer complications.