U-Rate-UE; Measuring perceived recovery of the affected upper extremity in adults post-stroke

OBJECTIVE

To establish initial validity of 'U-Rate-UE', a single-question scale regarding perceived recovery of the stroke affected upper extremity (UE).

DESIGN

A retrospective longitudinal study of data collected at rehabilitation admission, 6-weeks, 6-months since stroke.

SETTING

Stroke rehabilitation and community-based PARTICIPANTS: A convenience sample of 87 individuals, median (interquartile range) age 71.5 (65-80) years, 15.0 (12-20) days post-stroke INTERVENTIONS: Not applicable.

MAIN OUTCOME MEASURES

The affected UE was assessed using the Fugl-Meyer Motor Assessment, grip strength, Action Research Arm Test, the Box and Block Test (BBT) and The Rating of Everyday Arm-Use in the Community and Home. Participants also rated how much they perceive that their affected UE recovered from the stroke using U-Rate-UE; 0-100 (no to full recovery). Longitudinal changes in U-Rate-UE ratings were assessed. In addition, at 6-weeks and 6-months post-stroke, the change in BBT was calculated and participants were grouped into achieved/did not achieve the Minimal Detectible Change (MDC). Correlations between U-Rate-UE to the other UE assessments were assessed at all 3-timepoints.

RESULTS

Significant changes in U-Rate-UE were seen over time (p<.05). At 6-weeks and 6-months, participants who achieved BBT-MDC rated their recovery significantly higher than participants who did not. U-Rate-UE was moderately-strongly significantly correlated to UE assessments (rho=.61-.85, p<.001).

CONCLUSIONS

The U-Rate-UE is supported for use with UE assessments contributing to comprehensive clinical understanding of the recovery of the affected UE in adults post-stroke.

A digital exercise and augmented reality training system improved mobility among stroke patients: A randomized control trial

BACKGROUND

The Selfit system was developed to improve the mobility and gait-related functions of stroke patients by providing digital exercises and augmented reality training system.

OBJECTIVE

To evaluate the effects of a digital exercise and augmented reality training system on mobility, gait-related functions and self-efficacy outcomes in stroke patients.

METHODS

A randomized control trial was conducted on 25 men and women diagnosed with an early sub-acute stroke. Patients were randomly assigned to either the intervention (N= 11) or the control groups (N= 14). Patients in the intervention group received a digital exercise and augmented reality training using the Selfit system in addition to the standard physical therapy treatment. Patients in the control group were treated with a conventional physical therapy program. Timed Up and Go (TUG) test, 10-meter walk test, the Dynamic Gait Index (DGI), and the Activity-specific Balance Confidence (ABC) scale were completed before and after the intervention. Feasibility and satisfaction among patients and therapists were also assessed after the completion of the study.

RESULTS

The intervention group practiced proportionally more time per session than the control group with a mean change of 19.7% following 6 sessions (p= 0.002). The intervention group showed better improvement in post-TUG score compared to the control group (p= 0.04). ABC, DGI, and the 10-meter walk test scores were not significantly different between the groups. Both therapists and participants demonstrated high satisfaction with the Selfit system.

CONCLUSION

The findings suggest that Selfit holds promise as an effective intervention for improving mobility and gait-related functions among patients with an early sub-acute stroke as compared to conventional physical therapy treatments.

Higher cognitive load interferes with head-hand coordination: virtual reality-based study

Daily life activities often involve decision-based reaching movements in different contexts and circumstances. These activities span a wide array of cognitive load types we face while executing motor functions. Here we use a virtual reality-based neurocognitive testing platform to assess cognitive-induced changes in motor behavior as reflected by modulations in head-hand coordination. Our paradigm is based on the Color Trails Test (CTT), which is designed to assess two types of cognitive functions: Trails A-sustained visual attention (SVA), and Trails B-divided attention (DA). The virtual reality CTT adaptation (VR-CTT) requires execution of large multi-directional hand movements and head rotations. We employed a cross-correlation analysis on hand and head kinematics data collected from 122 healthy participants (ages: 20-90 years; divided as follows: young, middle-aged, and older adults) who completed the VR-CTT. The level of spatial coherence of head-hand movements was found to be high (R ≥ 0.76) in both Trails A and B, in all age groups. However, assessing head-hand phase shifts revealed longer time lags (i.e., in which head leads hand) in Trails B versus Trails A, in all age groups. We conclude that allocating cognitive resources to DA task reduces head-hand synchrony as compared to SVA conditions.

A randomized controlled trial of add-on naproxen, simvastatin and their combination for the treatment of schizophrenia or schizoaffective disorder

This large randomized controlled trial examined the effect of naproxen, simvastatin or both on patients with schizophrenia. This was a large multi-center, twelve-week, randomized, double-blind, placebo-controlled, four-arm clinical trial administering naproxen, simvastatin or both to 232 subjects with schizophrenia or schizoaffective disorder. The primary outcome was change in PANSS total score. ANCOVA and mixed model analyses of the PANSS total score change showed no significant difference between naproxen and placebo (adjusted p = 0.78), simvastatin and placebo (adjusted p = 0.38) or the combination of naproxen and simvastatin compared to placebo (adjusted p = 0.72). No statistically significant drug-placebo differences were found in the PANSS subscales, CGI or BACS between all groups. There was a near significant improvement in negative symptoms (p = 0.06), and an analysis of the 5 factor PANSS factors analysis found a significant improvement in simvastatin above placebo in withdrawal (p = 0.03). These finding were not significant after correcting for multiple comparisons. A meta-analysis on changes in total PANSS scores in studies on statins in schizophrenia, including the present study together with six other studies showed a significant improvement for statins compared to placebo (Hedges' G of -0.245 (CI= -0.403, -0.086, p = 0.002). When one outlying study which showed particularly strong effects of statins was removed, part of the effect went away. In conclusion, in this study, naproxen and simvastatin alone or in combination were not efficacious in the treatment of symptoms in schizophrenia. However, the meta-analysis of all studies of simvastatin for schizophrenia indicates further research on this topic.

Determinants of Quality of Life in Individuals With Spinal Cord Injury Using Structural Equation Modeling

OBJECTIVE

The objective of this study is to examine the interdependent associations between International Classification of Functioning, Disability and Health (ICF) domains and their relationship with environmental factors with regard to quality of life (QoL) in individuals with spinal cord injury (SCI).

DESIGN

Survey, cross-sectional study, and model testing using structural equation modeling.

SETTING

Two inpatient and outpatient SCI rehabilitation units, Sheba Medical Center and Loewenstein Hospital, Israel.

PARTICIPANTS

Convenience sample of 156 individuals with SCI (N=156).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

QoL assessed by the World Health Organization Quality of Life Assessment-BREF. Neurological impairment after SCI reflected by lesion completeness and neurologic level of injury as measured by the International Standards for Neurological Classification of Spinal Cord Injury. The Spinal Cord Independence Measure to assess SCI-related task performance. ICF Brief Core Sets composition scores to assess impairment in body structure and function domains, limitations in activities, restriction in participation constructs, and the effect of environmental factors within the ICF model.

RESULTS

Level of spinal cord injury and ICF Brief Core Sets composite score relating to activities and participation construct demonstrated a direct significant association with QoL. Moreover, a significant indirect association with QoL was found between the composite scores in ICF body structure and function and environmental factors, level of spinal cord injury, time since injury onset, and sex. Because the Spinal Cord Independence Measure was not related to QoL, we inferred that the categories related to instrumental activities of daily living and participation exert the most significant influence on QoL.

CONCLUSIONS

In order to optimize improvements in quality of life, current rehabilitation programs should target limitations specifically related to instrumental activities of daily living and participation restrictions. It may serve as a focal point for further development of current therapeutic models and analytical methods that optimize rehabilitation planning and decision making among both health care professionals and patients.

Less-Affected Hand Function Is Associated With Independence in Daily Living: A Longitudinal Study Poststroke

BACKGROUND AND PURPOSE

The upper extremity (UE) ipsilateral to the brain lesion is mildly affected poststroke. It is unclear whether patients perceive this, and the association between less-affected hand function and independence in activities of daily living (ADL) is unknown. We aimed to (1) assess longitudinal changes in function, dexterity, grip strength, and self-perception of the less-affected UE, (2) compare them to the normative data, and (3) determine the association of both UEs to ADL during the first 6 months poststroke.

METHODS

Consecutive adults following a first stroke were assessed on rehabilitation admission (T1), 6 weeks (T2), and 6 months (T3) poststroke onset. Box and block test assessed function of both UEs. The functional dexterity test (FDT) and Jamar Dynamometer assessed dexterity and grip strength of the less-affected UE. The functional independence measure assessed ADL, and instrumental ADL was assessed at T3. Spearman correlations and multiple regression models were used.

RESULTS

Participants were assessed at T1 (N=87), T2 (N=82), and T3 (N=68). At T1, less-affected UE deficits were apparent (median [interquartile range] box and block test-45 [35-53] blocks, FDT-44.5 [33.3-60.8] seconds, grip-25.5 [16.2-33.9] kilograms), but only 19.5% of the participants self-perceived this. Less-affected hand function significantly improved with 32% and 33% achieving a minimal clinically important difference for box and block test at T2 and T3, respectively. Dexterity improved significantly between T1 and T2 (P<0.001, no established minimal clinically important difference) and grip strength improved significantly between T2 and T3; 3.4% achieving a minimal clinically important difference (P<0.01). At T3, most participants did not reach the norms (box and block test-67.4 blocks, FDT-32.2 seconds, grip-40.5 kilograms). Both the less- and more-affected UEs explained a large portion of the variance of ADL at all time-points, after controlling for age, days-since-stroke-onset, stroke type, and cognition.

CONCLUSIONS

Despite some improvement, the less-affected UE at 6 months poststroke remained below norms, explaining difficulties in ADL and instrumental ADL. Further research is needed.

Improvement of the Upper Extremity at the Subacute Stage Poststroke: Does Hand Dominance Play a Role?

BACKGROUND

The impact of hand dominance on the expected (motor and functional ability and daily use) improvement of the affected upper extremity (UE) in subacute stroke has not yet been investigated.

OBJECTIVES

To compare between the affected dominant and affected nondominant UE (1) on rehabilitation admission (T1) for motor and sensory abilities, functional ability, and daily use and (2) 6 weeks poststroke onset (T2) and the UE recovery between T1 and T2 regarding percent change, improvement effect size, and percent of participants achieving minimal clinical important difference (MCID).

METHODS

Multicenter longitudinal study.

RESULTS

Thirty-eight participants with affected dominant and 51 participants with affected nondominant UE were recruited. On T1 and T2, between-group differences were not seen for all UE variables. Significant improvement in the motor and functional ability, daily use, and perceived recovery between T1 and T2 were seen for the affected dominant (z = -3.01 to -4.13, P < .01) and nondominant UEs (z = -4.59 to -5.32, P < .01). Effect size improvement values were moderate and large in the affected dominant and nondominant UE (respectively). In addition, 14% to 40% of the participants in both UEs achieved MCID.

CONCLUSIONS

Significant and similar clinical meaningfulness in UE improvement can be expected during subacute rehabilitation; however, improvement magnitude and percent improvement is different for the UE domains of the affected dominant and the affected nondominant UEs. These findings highlight the distinct roles of the dominant and nondominant hands during bimanual daily activities, which can guide clinicians during stroke rehabilitation.

The Recovery of the Less-Affected Upper Extremity (UE) During the First Six Months Poststroke

Date Presented 03/26/20

Weakness of the affected UE is common poststroke. However, it is important to be aware that the less-affected UE is also mildly affected poststroke. In this longitudinal study, we revealed that the motor and functional ability of the less-affected UE improved significantly during the first six months poststroke. The impact of this UE on bilateral functioning needs to be further investigated.

Primary Author and Speaker: Samar Hmaied Assadi

Additional Authors and Speakers: Debbie Rand

Contributing Authors: Noa Doron, Shelly Peri, Haim Barel, Israel Dudkiewicz, Gabi Zeilig, Revital Gross-Nevo

The Landing Error Scoring System Real-Time test as a predictive tool for knee injuries: A historical cohort study

PURPOSE

To assess the value of the Landing error score system - real time test as a predictive tool for knee injuries among combat soldiers in the Israeli defense forces.

METHODS

All 2474 Israeli defense forces' combat soldiers enrolled at the Israeli defense forces Injury Prevention and Rehabilitation Center were included. A retrospective cohort study was conducted. The predictive variable assessed was the landing error score system - real time score. The three main outcome variables were the incidence of overuse knee injuries, the meniscal injury, and the anterior cruciate ligament injury. Receiver operator characteristic analysis was performed to evaluate the test's potential as a predictive tool and in order to establish optimal cutoff scores.

RESULTS

The area under the curve of the receiver operation curves demonstrated no predictive value of the landing error score system - real time test for all three outcome variables (knee injuries: area under the curve 0.526, 95% confidence interval 0.498, 0.554, anterior cruciate ligament injuries: area under the curve 0.496, 95% confidence interval 0.337, 0.656, meniscus injuries: area under the curve 0.515, 95% confidence interval 0.454, 0.576).

INTERPRETATION

Based on the results of this study, the landing error score system - real time test has no predictive value for knee overuse injuries, meniscal injuries, and anterior cruciate ligament injuries. However, due to the small number of cases of anterior cruciate ligament injuries, the predictive value for anterior cruciate ligament injuries of this test should be further investigated.

The Association Between History of an Ankle Sprain and Traumatic Meniscal Injury Among Infantry Combat Soldiers in the Israeli Defense Forces: A Historical Cohort Study

Introduction

The high frequency and number of ankle inversion injuries and meniscal injuries in military populations is an area of concern due to the debilitating effects and cumulative consequences of these particular injuries on the soldiers sustaining injury and the consequences on the operational effectiveness of the Israeli Defense Force (IDF). This study examines the possible relationship between ankle inversion injury and potential for subsequent meniscal injury in infantry soldiers in the IDF.

Material and Methods

All 89,069 infantry combat soldiers (including special units), recruited to the IDF between 2007 and 2017 were included in this study. A historical cohort study was conducted. The cohort was divided into two groups: The exposure group included all participants that had suffered at least one ankle sprain in the past and the unexposed group that included all participants who did not suffer an ankle sprain in the past. A Cox proportional-hazards model (COX) model was used in order to obtain the adjusted to confounders association between exposure and outcome expressed in hazard ratio (HR).

Results

The crude association between ankle sprain in the past and the development of meniscal injury in this study was 0.87 (Relative risk = 0.87, P = 0.007). After adjusting for unit type, Body Mass Index (BMI), previous fracture of the lower limb, and the use of eyeglasses, using a COX model, the adjusted association between ankle sprain in the past and the development of meniscal injury was 0.8 (HR = 0.8, P = 0.001, confidence interval (95%) 0.74, 0.88).

Conclusion

The results of this study indicate ankle sprains to be a protective factor for meniscal injury. Our main conclusion from the results of this study is that the assumption that those with previous leg injuries are at a greater risk for further leg injuries is questionable and cannot be generalized. Hence, the association between different types of injuries should be investigated separately.

Overuse Injuries Among Female Combat Warriors in the Israeli Defense Forces: A Cross-sectional Study

Introduction

Integration of females in combat units poses a unique challenge for army commanders around the world. The purpose of this study is to provide a detailed up-to-date situation report regarding overuse injuries among combat female warriors in the IDF (Israeli Defense Forces) in order to enable evidence-based decision-making, prevention policy, and further research of this highly significant military public health issue.

Methods

A cross-sectional descriptive study was conducted including 2,519 females recruited to combat duties during the year of 2013. The main data source was the IDF's computerized medical consultation records package (CPR). Descriptive statistics was performed and some results were compared with males using data from other reports and studies of the IDF.

Results

The overall injury rate was 28.3%. Of all injuries, 86% were in the ankle and calf (41%), the lower back (23%), and the knee (22%) regions. The average lost training days was 11 d for females as compared with 8 d for males. The overall rates of stress fractures and the rates of femur and femoral neck stress fractures were significantly higher among females as compared with males (11.2% vs. 2.5%, p = 0.0032, and 7.8% vs. 1.6% p = 0.00001, respectively).

Conclusions

The overuse injury rates among females in the IDF are high and may be considered a significant military public health problem. In order to reduce the numbers of overuse injuries, which is expected to significantly increase after the IDF's policy change regarding to combat duties open for females, we recommend planning and implementation of policies and intervention programs and further research regarding to overuse injuries among female combat warriors with special focus on the calf and ankle, lower back, and knee regions and femoral stress fractures.

Overuse Injuries in the IDF's Combat Training Units: Rates, Types, and Mechanisms of Injury

Introduction

Overuse injuries are responsible for most lost training days and attrition from combat training in the Israeli Defense Forces (IDF) as in armies around the world. The purpose of this study is to understand the rates, types, and mechanism of occurrence of overuse injuries in the IDF in order to provide the IDF's commanders a detailed updated situation report in order to enable commanders decision-making, prevention policy, and further research of this highly significant military public health issue.

Methods

A cross-sectional study including 20,000 soldiers recruited to combat units during the year of 2013 was performed. Most of the data were collected from the IDF's computerized medical consultation records package. Descriptive statistics (percent, mean, standard deviation, and median) were used in order to express results. The study was approved by the IDF's institutional review board.

Results

The overall injury rate was 24.5%. The total number of injuries was 6,393 with an average of 1.32 ± 0.22 injuries per injured soldier. The injury rate was 18.4% in the infantry units and 36.1% in non-infantry units. Of all injuries, 87% occurred in the lower back and lower limb regions. The most frequent injury sites were the calf and ankle (34%), the knee region (22%), and the lower back (19%). Of all injuries, 74% occurred during running (45%) or long-distance walking (29%). The average lost training days due to injuries was 9 d per soldier and 6.5 d per injury. The total number of stress fractures was 494-2.5% of all soldiers (four fractures per 100 person years). The calf and ankle region was the most frequent site of stress fractures and accounted for 84% of all stress fractures, the vast majority of them (95%) were fractures of the distal tibia. The average number of lost training days due to stress fractures was 16 ± 6.1 per fracture.

Conclusions

As in other armies around the world, overuse injuries in the IDF are a major public health problem and poses a significant challenge to the IDF's commanders and the medical corps policy leaders. Further studies should be performed in order to identify the risk factors for these injuries especially in the lower back and the lower limb regions as part of the effort to try and reduce the rates of these injuries as much as possible. This study emphasizes the need for a continuous surveillance and monitoring system for overuse injuries as a significant and integral component of any intervention plan in the domain of overuse injuries.

The Prevalence and Body Site Distribution of Stress Fractures among Female Combat Soldiers in the Israeli Defense Forces: A Cross-Sectional Study

One of the most troublesome overuse injuries is stress fractures, for which female gender is a major risk factor. In 2015, the Israeli government opened identical combat duties for both genders. The purpose of this study is to provide a detailed report regarding the prevalence and characteristics of stress fractures in females that will serve as an evidence-based platform for future policy planning and implementation regarding female integration in combat units. This is a report of a cross-sectional study of 2223 female soldiers recruited to combat units between 2010 and 2013. Data were collected from the Israeli Defense Force's (IDF's) computerized medical consultation records package. Descriptive and analytic statistics were performed to obtain and analyze results. The overall stress fractures rate was 11.6% (258 soldiers). The most frequent site for stress fracture was the distal tibia (215 cases, 83%). The average lost training days due to a stress fracture were 26.6 days. The risk for developing a stress fracture was 2.15 (215%) times higher in the noninfantry group than in the infantry group, ( p = 0.0232, 95% confidence interval 1.346, 4.536). The rate of stress fractures and the consequent lost training days in the IDF are high and necessitate the planning and implementation of a comprehensive intervention policy to reduce overuse injuries and stress fracture rates among female warriors.

Markers of muscle damage for comparing soft tissue injury following proximal femur nail and dynamic hip screw operations for intertrochanteric hip fractures

BACKGROUND

Femoral neck fractures are the most common fractures among the elderly. The two operative approaches used for the treatment of AO/OTA 31 intertrochanteric fractures include an intramedullary device (proximal femoral nail [PFN]) or an extramedullary device (sliding/dynamic hip screw [DHS]). The aim of this study was to provide objective evidence of local soft tissue injury by measuring serum creatine phosphokinase (CPK), a biochemical marker, to quantify muscle damage and inflammation in patients treated by the two approaches.

PATIENTS AND METHODS

Medical data of 359 patients operated for intertrochanteric fractures with PFN (156 patients) or DHS (193 patients) were retrospectively reviewed. The fractures were classified according to AO/OTA classification. Perioperative and radiographic data were collected to ensure cohorts with similar characteristics. Serum CPK and serum hemoglobin (Hb) levels were measured preoperatively and on postoperative day 1 (POD1). Independent predictors of elevation in the levels of markers of inflammation and muscle damage were determined by a multivariate linear regression model.

RESULTS

The demographics were similar for the two groups. Our study population included 64.2% female patients. Preoperative serum CPK levels were available for 89 patients and POD1 serum CPK levels were available for all patients. One-hundred and thirteen of the 193 DHS patients (58%) and 14 of the 156 PFN patients (9%) had a stable fracture (AO/OTA 31A1, p<0.0001). The DHS patients had a greater increase between pre- and postoperative CPK levels compared to the PFN patients (DHS, δ=368 versus PFN, δ=65, p<0.0002). The PFN patients had a greater decrease in both the pre- and postoperative Hb levels compared to the DHS patients (Diff_Hb 0.27g/dl). The older the patient, the greater decreases in Diff_CPK compared to the younger ones.

CONCLUSIONS

Implementation of POD1 CPK blood levels as a biochemical marker of soft tissue injury provided quantitative evidence that patients whose intertrochanteric fracture was stabilized by a DHS suffered greater soft tissue injury compared to patients whose fracture was stabilized by a PFN.

Locking versus standard screw fixation for acetabular cups: is there a difference?

INTRODUCTION

Total hip replacement has been established as a valid treatment option for displaced subcapital fractures. However, insufficient primary fixation may be the reason for early loosening in these osteoporotic patients. Primary fixation of the cup is usually achieved by press-fit fixation that can be enhanced using screws. Locking the screws into their respective cups may seem to improve the primary fixation of the construct, as locked plates proved superior fixation for osteoporotic fractures.

METHODS

The study consisted of three groups: in each group, three cups were fixed into blocks of foam bone using press-fit technique. In the first group, no additional screws were used, in the second group two standard screws were inserted, while in the third group two acetabular screws were cemented into the cup to simulate locked screw fixation. Load was applied onto the rim of the acetabular component to cause shearing between the cup and the block. Cup fixation was examined by a loading machine that acquired load versus displacement. The stiffness (load vs. displacement) was calculated.

RESULTS

Screws, either locked or non-locked, enhanced cup fixation by 26 % (p value <0.01). No significant changes were found between the locking and non-locking screws groups.

DISCUSSION

These experimental results indicate that acetabular screws enhance primary cup fixation. This may become significant in conditions where the acetabular bone stock is suboptimal, such as when performing total hip arthroplasty after displaced subcapital fractures. However, there is no superiority for locked screws over standard screw fixation.

Safety and tolerance of the ReWalk™ exoskeleton suit for ambulation by people with complete spinal cord injury: a pilot study

OBJECTIVES

The objective of the study was to evaluate the safety and tolerance of use of the ReWalk™ exoskeleton ambulation system in people with spinal cord injury. Measures of functional ambulation were also assessed and correlated to neurological spinal cord level, age, and duration since injury.

STUDY DESIGN

Case series observational study.

SETTING

A national spinal cord injury centre.

METHODS

Six volunteer participants were recruited from the follow-up outpatient clinic. Safety was assessed with regard to falls, status of the skin, status of the spine and joints, blood pressure, pulse, and electrocardiography (ECG). Pain and fatigue were graded by the participants using a visual analogue scale pre- and post-training. Participants completed a 10-statement questionnaire regarding safety, comfort, and secondary medical effects. After being able to walk 100 m, timed up and go, distance walked in 6 minutes and 10-m timed walk were measured.

RESULTS

There were no adverse safety events. Use of the system was generally well tolerated, with no increase in pain and a moderate level of fatigue after use. Individuals with lower level of spinal cord injury performed walking more efficiently.

CONCLUSION

Volunteer participants were able to ambulate with the ReWalk™ for a distance of 100 m, with no adverse effects during the course of an average of 13-14 training sessions. The participants were generally positive regarding the use of the system.

Functional and environmental factors affecting work status in individuals with longstanding poliomyelitis

INTRODUCTION

Remunerative employment is a major concern of individuals with chronic disabilities, among them, those with longstanding poliomyelitis (LSP). Although LSP is not rare there are almost no data related to work participation.

PURPOSE

The aims of the current study were to determine the effects of a number of social and functional variables as barriers or facilitators to work participation in persons with LSP.

PATIENTS AND METHODS

Charts of 123 LSP patients of working age that were seen in the post-polio outpatient clinic, between the years 2000 and 2005 were reviewed for the study. Data on age, gender, family status, level of function in activities of daily living, basic, and extended (B-ADL and E-ADL), and mobility were then analyzed for correlation to the vocational status.

RESULTS

Seventy-two people (58.5%) were employed at the time of the survey. Gender and marital status were not found to significantly differ as regard to employment. Using assistive devices for mobility or being dependent for basic ADL were associated with lower levels of employment. Driving was positively associated with the employment status of the LSP individuals.

CONCLUSION

Persons with LSP encounter important barriers to work participation, particularly on the International Classification of Functioning, Disability, and Health (ICF) components of activity and environment.

Do weight-bearing films affect decision making in hallux valgus surgery?

Hallux valgus is a complex deformity of the first ray and forefoot that can be surgically treated using different procedures and osteotomies. Preoperative planning includes anteroposterior and lateral plain films. The effect of weight-bearing on the results of the standardized measurements is still the subject of debate. We evaluated the effect of weight-bearing on the results of measurements and decision making by expert evaluators. A total of 21 foot and ankle surgeons were given weight-bearing and non-weight-bearing anteroposterior plain foot films of patients with hallux valgus. They were asked to measure 3 standard angles and then to select the most appropriate procedure from a short list. Using a paired Student's t test, no difference in the angles measured nor in the procedures chosen was detected between the weight-bearing and non-weight-bearing films. Although it is generally accepted that decisions regarding the treatment of hallux valgus should be based on plain weight-bearing films, in the present study, we established that non-weight-bearing films can reliably be used to choose the surgical procedure.

THE EFFECTS OF USING A TOURNIQUET IN TOTAL KNEE ARTHROPLASTY: A STUDY OF 77 PATIENTS

Introduction: Total Knee Arthroplasty (TKA) is usually performed with a tourniquet. Previous studies investigated the relationship between tourniquet and blood loss. This study evaluated tourniquet usage regarding parameters such as blood loss, drainage, blood administration, knee flexion, and complications. Patients and Methods: A cohort of 77 patients who underwent total knee arthroplasty was reviewed. Results: No difference in 24-hours postoperative hemoglobin levels was observed. Blood collected in drains was slightly higher in the tourniquet group, yet there was more overall administration of blood for non-tourniquet group: a mean of 1.2 units of packed RBC versus a mean of 0.63 units for the tourniquet group. Complication rate was comparable, but a higher rate of local infection in tourniquet group was observed. No thromboembolic events were observed. Conclusion: With regards to direct blood loss parameters, there was no statistical difference between groups, provided that meticulous hemostasis is undertaken. Operating without a tourniquet poses a risk of increased demand for blood products. There is also some concern regarding local complication rate when tourniquets are used.

Ankle tourniquet pain control in forefoot surgery: a randomized study

BACKGROUND

Forefoot surgery is often performed under regional anesthesia in awake patients, using tourniquet or Esmarch bandage to obtain a bloodless field. The purpose of this study was to examine the value and need for local tourniquet pain control using local subcutaneous analgesic mixture in patients undergoing forefoot surgery under ankle block anesthesia.

MATERIALS AND METHODS

We prospectively randomized 56 patients who underwent forefoot surgery under ankle block to receive either subcutaneous local anesthetic mixture under the tourniquet or no additional anesthetic. We checked for local tourniquet pain score (VAS 0 to 100) and skin condition during and after the procedure.

RESULTS

The tourniquet was quite tolerable in both groups, with an average VAS score of 7 to 21. No difference was observed between groups throughout most of the procedure. No correlation between VAS scores and procedure length or patient's age or gender was found.

CONCLUSION

An ankle tourniquet was well-tolerated by patients without need for local anesthetic beneath the cuff.

Trends in femoroacetabular impingement research over 11 years

Femoroacetabular impingement is the abutment between the proximal femur and the rim of the acetabulum. It is a common cause of labral injury that has been identified as an early cause of hip osteoarthritis. The diagnosis of femoroacetabular impingement of the hip is currently well defined in orthopedic surgery but should attract the attention of physicians in other disciplines. Conversely, much less is known about the etiology and natural history of femoroacetabular impingement.The goal of this study was to assess the number of articles published on femoroacetabular impingement over 11 years in orthopedic vs nonorthopedic medical journals, and to evaluate the quality of available evidence. PubMed and OvidSP databases were searched for articles on femoroacetabular impingement published from 1999 to 2009. Articles were characterized by publication type and journal type per year. Regression analysis was used to determine the effect of publication year on number of publications of each type. The search yielded 206 publications on femoroacetabular impingement during the evaluation period. Seventy-two percent were published in orthopedic journals. Overall, the number of publications increased exponentially with time. There was an increase in clinical trials over the course of the study period. However, studies with high-quality evidence were scarce. The increase in data from orthopedic and nonorthopedic disciplines is welcome. Nevertheless, high-quality evidence on femoroacetabular impingement is lacking. We believe the current trend toward evidence-based orthopedic surgery will impact future research on this relatively new disorder.

Lengthening of the shortened first metatarsal after Wilson’s osteotomy for hallux valgus

Metatarsalgia is a recognised complication following iatrogenic shortening of the first metatarsal in the management of hallux valgus. The traditional surgical treatment is by shortening osteotomies of the lesser metatarsals.

We describe the results of lengthening of iatrogenic first brachymetatarsia in 16 females. A Scarf-type osteotomy was used in the first four cases and a step-cut of equal thicknesses along the axis of the first metatarsal was performed in the others.

The mean follow-up was 21 months (19 to 26). Relief of metatarsalgia was obtained in the six patients in whom 10 mm of lengthening had been achieved, compared to only 50% relief in those where less than 8 mm of lengthening had been gained.

One-stage step-cut lengthening osteotomy of the first metatarsal may be preferable to shortening osteotomies of the lesser metatarsals in the treatment of metatarsalgia following surgical shortening of the first metatarsal.

Trans-metatarsal amputation in patients with a diabetic foot: reviewing 10 years experience

Considerable disagreement exists whether trans-metatarsal amputations are indicated in persons with diabetes. A previous study reported that statistically the success rate of Syme's amputation in diabetic patients over 65 years of age resulted in a very poor results. The purpose of this study was to investigate the results of trans-metatarsal amputations, in patients with diabetes and to seek markers which could shed light upon the advantages/disadvantages of this procedure. The records of 46 patients covering a 10-year period (1996-2006) were used as a database. Twelve needed higher amputation level and another 10 needed a wound revision. All the patients that maintained the original amputation level walk without a need for a prosthesis and kept their previous abode. TMA in diabetic patients, although at a high risk for an extrasurgical procedure, once successful, the patient will regain his previous lifestyle.

Treating civilian gunshot wounds to the extremities in a level 1 trauma center: our experience and recommendations

BACKGROUND

Gunshot wounds impose a continuous burden on community and hospital resources. Gunshot injuries to the extremities might involve complex soft tissue, bone, vascular, musculotendinous, and nerve injuries. A precise knowledge of anatomy is needed to evaluate and treat those injuries.

OBJECTIVES

To review our experience with gunshot wounds to the extremities.

METHODS

We retrospectively reviewed all civilian cases of gunshot wounds to the limbs treated in our institution during 2003-2005. Altogether, we evaluated 60 patients with 77 injuries.

RESULTS

Of the 60 patients 36 had fractures, 75% of them in the lower extremity and 81% in long bones. The most common fixation modality used was external fixation (33%), followed by intramedullary nailing (25%). This relatively high percentage of fracture treated with external fixation may be attributed to the comminuted pattern of the fractures, the general status of the patient, or the local soft tissue problems encountered in gunshot wounds. About one-fifth of the fractures were treated by debridement only without hardware fixation. We treated 10 vascular injuries in 8 patients; 6 of them were injuries to the popliteal vessels. Fractures around the knee comprised the highest risk factor for vascular injuries, since 5 of the 12 fractures around the knee were associated with vascular injury requiring repair or reconstruction. There were 13 nerve injuries (16.8%), most of them of the deep peroneal nerve (38%). Only three patients had concomitant nerve and vascular injuries. The overall direct complication rate in our series was 20%.

CONCLUSIONS

To successfully treat complex gunshot injuries a team approach is necessary. This team should be led by an orthopedic surgeon knowledgeable in the functional anatomy of the limbs.

A review of the aetiological factors and results of trans-ankle (Syme) disarticulations

INTRODUCTION

Ever since James Syme described his amputation at the ankle joint, most authors have agreed that Syme's amputation should not be considered for patients with diabetic vascular disease (DVD). The aim of the study was to record our experience with Syme's amputations and to search for any predictive criteria that may enhance successful results.

PATIENTS AND METHODS

Seventy patients underwent a Syme amputation between the years 1980 and 2000 in our department, 51 owing to DVD. The other 19 patients had their amputations because of other pathologies.

RESULTS

The 19 patients of the non-DVD group showed a success rate of 94.7% (18/19). The overall success rate of the DVD patients was 49% (25/51). When we analysed the DVD group by age, the cut-off point was 65 years old. Patients aged 65 or less had a success rate of 68.2% (15/22), and over the age of 65 years the success rate was only 30.8% (8/26).

CONCLUSIONS

Patients with DVD should be considered good candidates for a Syme amputation if they are younger than 65 years old.

Biomechanical properties of new mini compression screws

BACKGROUND

The aim of the current study was to compare the compression forces achieved by the new commercial mini compression screws in cortical and cancellous bone.

MATERIALS AND METHODS

The following screws were tested: AO partially threaded 4-mm cancellous screw, AO 3.5- and 2.7-mm cortical screws (Synthes - USA) , self-tapping cannulated 3-mm VisAntares (EOS - France), 3- and 2.3-mm Omnitech (Biotech - France), 3-mm Barouk (DePuy - France), and 3-mm Bold screws (Newdeal - France). The compression forces of screws in bone were tested using a load cell between pieces of longitudinally-split sheep tibias as a cortical and cancellous bone model.

RESULTS

The AO 3.5-mm, 2.7-mm cortical and 4.0-mm partially threaded cancellous headed screws provided significantly (p < = 0.05) better compression forces than all the tested headless screws, both in cortical and cancellous bone. A loss of compression was noted when the headless screws were totally countersunk.

CONCLUSION

The cortical and cancellous screws with heads provided superior compression than headless screws.

CLINICAL RELEVANCE

Headed screws may be preferable to headless differential pitch screws in situations where compression is important ie, arthrodeses or fracture fixation. Care should be taken not to countersink the headless screws during insertion into cortical bone.

Elastofibroma at the scapular region

BACKGROUND

Elastofibroma is a rare type of lesion consisting of elastic fibers within a stroma of collagen and fatty tissue. It is usually located on the lower scapular region attached firmly to the thoracic cage, often causing debilitating pain. Its clinical presentation mimics a soft tissue tumor.

OBJECTIVES

To evaluate the diagnosis and treatment results of elastofibroma.

METHODS

Clinical and radiographic evaluations were performed in 11 patients with thoracic wall mass. In five of them a biopsy was taken before surgery. All patients were operated and the diagnosis of elastofibroma was confirmed by histology.

RESULTS

Two patients had a postoperative seroma that resolved spontaneously within a few days. All patients reesumed their preoperative activities, including sports.

CONCLUSIONS

Considering the slow-growing nature of this tumor and its typical presentation, we believe that when this diagnosis is suspected, investigation does not necessitate staging (as in sarcomas). Also, marginal surgical excision is sufficient. Observation is an acceptable alternative to surgery.

The effects of prolonged deep freezing on the biomechanical properties of osteochondral allografts

Musculo-skeletal allografts sterilized and deep frozen are among the most common human tissue to be preserved and utilized in modern medicine. The effects of a long deep freezing period on cortical bone has already been evaluated and found to be insignificant. However, there are no reports about the influences of a protracted deep freezing period on osteochondral allografts. One hundred osteochondral cylinders were taken from a fresh specimen and humeral heads of 1 year, 2 years, 3 years and 4 year old bones. Twenty chips from each period, with a minimum of 3 chips per humeral head. Each was mechanically tested by 3 point compression. The fresh osteochondral allografts were significantly mechanically better than the deep frozen osteochondral allografts. There was no statistical significant time dependent difference between the deep frozen groups in relation to the freezing period. Therefore, we conclude that, from the mechanical point of view deep freezing of osteochondral allografts over a period of 4 years, is safe without further deterioration of the biomechanical properties of the osteochondral allografts.

A method for quantifying dynamic muscle dysfunction in children and young adults with cerebral palsy

Cerebral palsy (CP) is caused by a lesion to the brain resulting in adaptations to the structure and function of the muscles and compromised mobility. Spastic cerebral palsy is commonly assessed by the limb kinematics and kinetics measured in a gait laboratory. However, these measures do not directly quantify the patterns of muscle dysfunction that occur during movements. Recent studies have shown that electromyographic (EMG) signals from children with CP have abnormal magnitude, timing and frequency content. Here we demonstrate how wavelet decomposition of the EMG signals into time-frequency space coupled to principal component analysis of the EMG spectra can be used as a powerful tool to quantify the patterns of muscle dysfunction. Data were compared between 17 children with spastic diplegic CP and 36 asymptomatic controls for the rectus femoris, semimembranosus, medial gastrocnemius and tibialis anterior muscles. CP muscle generated higher mean EMG frequencies. Imbalances in activity between the tibialis anterior and medial gatrocnemius contributed to equinus ankle during the swing phase. Patterns of co-activations between antagonistic muscles differed between CP and asymptomatic patients and were EMG frequency dependent. Muscle dysfunction was greater in the distal compared to the proximal lower limb. Muscle dysfunction between the tibialis anterior and medial gastrocnemius was distinguished with 96% sensitivity at 95% specificity.

Percutaneous Achilles tendon repair combined with real-time sonography

BACKGROUND

When encountering complaints of pain in the area of Achilles tendon with a suspected lesion, the clinician seldom reaches a precise diagnosis based only on X-ray and clinical examination. Ultrasonography is useful for evaluating the pathology and treatment.

OBJECTIVES

To assess the relative contribution of real-time intraoperative ultrasound examination and immediate postoperative ultrasound in patients with acute rupture of the Achilles tendon treated by percutaneous suture method. The combination of both procedures provides a unique advantage that could facilitate better results.

METHODS

Ultrasound examination was used in 20 patients with acute rupture of the Achilles tendon who were treated surgically. Intraoperative as well as postoperative ultrasound examinations were performed in 5 patients while 15 patients underwent an immediate postoperative ultrasound.

RESULTS

Ultrasound pathologies were found in all patients. Percutaneous surgical correction of ruptured Achilles tendon with accurate positioning of the foot using real-time sonography was successful in all the patients.

CONCLUSION

As in many other soft tissue lesions, ultrasonography is a useful tool for evaluating the pathology and for planning the surgical correction of ruptures in the Achilles tendon.

Thoracic and lumbar spine radiographs for walking trauma patients--is it necessary?

Numerous patients ambulating independently arrive in the Emergency Department complaining of back pain after being involved in a motor vehicle crash (MVC). We examined the yield of routine screening radiographs of the lumbar and thoracic spine in these patients. A retrospective review was carried out of the records of 3173 patients who were involved in a MVC during a 1-year period and presented to a single medical center. Radiographs of the lumbar spine, thoracic spine, or both were obtained in all patients complaining of back pain. Of 3173 ambulating MVC trauma patients, 35% (1110 patients) complained of thoracic or lumbar back pain. None of the lumbar and thoracic spine radiographs that were obtained in these patients was positive for a fracture or dislocation. The current study suggests that the yield of the routine use of spinal radiographs is very low in patients ambulating independently and complaining of back pain after a MVC.

Congenital muscular torticollis in infants: ultrasound-assisted diagnosis and evaluation

Ultrasonography is considered the modality of choice for differentiating congenital muscular torticollis from other pathologies in the neck. The authors present their experience with ultrasound examination for the evaluation and management of congenital muscular torticollis. Twenty-six infants, 14 boys and 12 girls, age ranging from 1 to 16 weeks, with torticollis and a palpable mass were examined. Ultrasound showed a well-defined mass in the sternocleidomastoid muscle. The lesions ranged in size from 8 to 15.8 mm on maximal transverse diameter, with length ranging from 13.7 to 45.8 mm. Clinically the torticollis disappeared between 1 to 6 weeks, with complete clinical reduction of the palpated mass between 2 and 8.5 weeks. The ultrasonographic disappearance of the mass was delayed by an average of 2 weeks in comparison to the clinical disappearance of the mass. Ultrasound is advocated for the diagnosis and follow-up of congenital muscular torticollis because it noninvasively provides reliable and dynamic information without sedation.

Colchicine inhibits fracture union and reduces bone strength--in vivo study

INTRODUCTION

Recent studies have demonstrated that Colchicine (CO) prevents heterotopic ossification (HO) after total hip replacement in patients suffering from familial Mediterranean fever (FMF). Other investigators have proved that CO is an in vitro inhibitor of proliferation of osteoblasts and osteosarcoma cells, and is a non-selective mitosis inhibitor and selective inhibitor of mineralization.

METHODS

A double blind prospective study comprised four groups of adult rats. The left posterior tibia in each rat was fractured except in one of the control groups. The study groups were treated with CO 1 mg/kg/day 1 week before, or on the fracture day. The control groups did not receive CO treatment. Six weeks after fracture induction the groups were compared radiographically mechanically and histologically.

RESULTS

Prolonged CO treatment had a significant negative influence on fracture healing according to radiological, clinical, mechanical (p<0.02), and pathological parameters (p<0.0001).

CONCLUSIONS

We were able to demonstrate that prolonged CO treatment reduced bone healing.

Trans-femoral amputee pilots: criteria for return to the fighter cockpit

Proximal lower limb amputations (trans-femoral) usually leave amputees with significant functional disturbances. This article contains information regarding three pilots with trans-femoral amputations that returned swiftly to continue their aeronautical careers despite their disabilities. Adaptations are needed in the limb prostheses to enable the amputees to access the minimally spaced cockpit.

Colchicine inhibits heterotopic ossification: experimental study in rabbits

BACKGROUND

Heterotopic ossification is a common complication of hip surgery and musculoskeletal or brain trauma.

OBJECTIVES

To confirm by in vivo study that colchicine inhibits osteoblast cell proliferation with marked decrease in tissue mineralization.

METHODS

Heterotopic ossification was induced in three groups of New Zealand white rabbits (females, 6 months old, weight 3-3.5 kg) by injecting 2 ml bone marrow drawn from the iliac crest into their right thigh muscle. To prevent heterotopic ossification, colchicine (0.25 mg/ day) was administered orally for 4 weeks to two groups of adult rabbits: group A (preload group)--1 week preceding bone marrow injection; group B--on day of injection; and group C--control group.

RESULTS

After 4 weeks the rabbits were evaluated by radiographs and ultrasound for evidence of heterotopic ossification. At the end of the study histologic samples were taken from all the thighs. Imaging and histologic studies showed, with statistical significance, almost complete prevention of heterotopic ossification formation in group A (preload) and a marked decrease in group B, when compared with the controls where large new bone had formed at the injection site. These results indicated the inhibitory effects of colchicine on a bone-forming process in soft tissue such as heterotopic ossification.

CONCLUSIONS

The role of colchicine in preventing heterotopic ossification in other bone-forming conditions, such as hip arthroplasty or pelvic trauma, and after brain trauma, remains to be evaluated in a clinical setting.

Ultrasonography as a diagnostic modality in acromioclavicular joint pathologies

BACKGROUND

Ultrasound is useful in detecting acromioclavicular pathologies in cases of trauma, inflammations and degenerative changes.

OBJECTIVES

To describe the sonographic findings of acromioclavicular joint pathology in patients with anterior shoulder pain.

METHODS

Sonographic examination of the ACJ was used to examine 30 adults with anterior shoulder pain. As a control group we studied 30 asymptomatic patients and compared the findings to plain radiographs of the symptomatic group.

RESULTS

The pathologic findings consisted of swelling of the joints, bone irregularities, widening and/or narrowing of the ACJ, soft tissue cyst formation, excessive fluid collection, and calcification. All these signs represent degenerative changes compatible with early osteoarthritis. We encountered one case of septic arthritis that required joint aspiration and antibiotic treatment.

CONCLUSIONS

It is our belief that ultrasonography should be used routinely in cases of anterior shoulder pain since it demonstrates various pathologies undetected by plain radiographs.

Idiopathic adhesive capsulitis: long-term results of conservative treatment

BACKGROUND

Adhesive capsulitis, also termed "frozen shoulder," is controversial by definition and diagnostic criteria that are not sufficiently understood. The clinical course of this condition is considered self-limiting and is divided into three clinical phases. Several treatment methods for adhesive capsulitis have been reported in the literature, none of which has proven superior to others.

OBJECTIVES

To evaluate the long-term follow-up of patients with idiopathic adhesive capsulitis who were treated conservatively.

METHODS

We conducted a long-term follow-up (range 5.5-16 years, mean 9.2 years) of 54 patients suffering from idiopathic adhesive capsulitis. All patients were treated with physical therapy and non-steroidal anti-inflammatory drugs.

RESULTS

An increased statistically significant improvement (P < 0.00001) was found between the first and last visits to the clinic in all measured movement directions: elevation and external and internal rotation.

CONCLUSIONS

Conservative treatment (physical therapy and NSAIDs) is a good long-term treatment regimen for idiopathic adhesive capsulitis.

Bone allograft in revision total knee replacement

Revision total knee replacement (TKR) is often associated with the necessity to reconstruct a certain amount of bone loss. In a retrospective study we reviewed the records of 137 patients who had undergone revision TKR in our department between 1990 and 1996, due to loosening or inflection. Bone allografts were used in 91 patients (67%) to accomplish stable, new prostheses. Three types of bone loss were identified in this group: Type I - minor, Type II - moderate, and Type III - large bone defects, located on either side of the knee joint - A, or both sides - B.The treatment results of these 91 patients, according to the type of bone loss, are presented, showing good functional outcome when utilizing bone allografts in revision TKR. However, careful preoperative planning, identification of bone loss type, and a well-equipped bone bank are mandatory to the success of the operation.

Evaluation of prosthetic usage in upper limb amputees

PURPOSE

Upper limb amputations cause severe functional disability and lower the patient's self body image, with severe psychological implications. Many parameters are involved in the successful rehabilitation of upper limb amputations. The aim of this study was to investigate whether there are any parameters that might predict the successful prosthetic rehabilitation of upper limb amputees.

METHOD

The records of 45 patients who had undergone an upper limb amputation were traced. The patients were evaluated according to four parameters: (1) Modified upper extremities amputees' questionnaire; (2) Pain level according to Visual Analog Scale (VAS), range from 1 (lowest) up to 10 (highest); (3) Pain type - phantom or pain in the stump; (4) Functional assessment of prosthetic usage.

RESULTS

Thirty (71.43%) of the patients reported difficulties with prosthesis usage. Twenty-three patients (54.76%) were satisfied with their prosthesis - 19 had cosmetic prosthesis and four had body-powered prosthesis.

CONCLUSION

No significant affect of the amputation level except for trans-wrist amputation with 100% prosthesis use. No significant difference was found between prosthesis type and the correlation to stump problems. The above-elbow amputees, with dominant hand amputation, who used functional prosthesis (body-powered), achieved the best functional outcome and result.

Total hip arthroplasty after avascular necrosis of the femoral head: does etiology affect the results?

INTRODUCTION

The aim of the study was to evaluate the results of total hip arthroplasty (THA) due to avascular necrosis (AVN) of the femoral head and to establish whether the cause of AVN affects the results.

MATERIAL AND METHODS

A group of 68 patients, 17-82 years of age (mean: 49.9 years) underwent 84 total hip arthroplasties due to AVN. The patients were divided into subgroups according to the etiology of AVN of the hip joint. The results of each group were evaluated by the Harris Hip score (HHS) at 3-18 years (mean: 6.2 years). The complication rate was also assessed.

RESULTS

The mean preoperative HHS was 28.5+/-4.5 as opposed to a postoperative HHS of 86+/-10. The revision rate was 16.7%. Etiology does not affect the final outcome, but less favorable long-term results were found in the steroid-induced AVN patients.

CONCLUSIONS

Despite the previously reported, less favorable results, THA is a good option for the younger population, even with AVN, especially in bilateral disease. Etiology did not affect the final outcome. However, patients with steroid-induced AVN should be informed that although their final functional results will equal those of other groups, the longevity of the implants is limited.