Distal femoral osteotomy and patellar tendon advancement for the treatment of crouch gait in patients with bilateral spastic cerebral palsy

BACKGROUND

Crouch gait, or flexed knee gait, represents a common gait pattern in patients with spastic bilateral cerebral palsy (CP). Distal femoral extension and/or shortening osteotomy (DFEO/DFSO) and patellar tendon advancement (PTA) can be considered as viable options when knee flexion contractures are involved. Better outcomes have been reported after a combination of both, independently of the presence of knee extensor lag. In this study, we evaluated the clinical and kinematic outcomes of these procedures.

PATIENTS AND METHODS

We reviewed a cohort of 52 limbs (28 patients) who were treated for crouch gait by DFEO/DFSO alone (group 1, n = 15) or DFEO/DFSO + PTA (group 2, n = 37) as a part of single event multilevel surgery (SEMLS). The mean age at surgery was 14 years, and the mean follow-up time was 18 months. The physical examination data and three-dimensional standardized gait analysis were collected and analyzed before the surgery and postoperatively.

RESULTS

Overall knee range of motion improved in all limbs. The knee flexion decreased significantly in both groups at initial, mid, and terminal stance. Hip flexion significantly decreased in mid-stance for limbs in group 2. Both clinical and gait parameters were most improved in limbs who underwent DFEO/DFSO + PTA. Increased pelvic tilt was observed in both groups after surgery.

CONCLUSION

Although DFEO/DFSO alone was successful in correcting knee flexion contractures, PTA has helped to improve knee extensor lag and knee extension during gait.

LEVEL OF EVIDENCE

Therapeutic level IV.

Treatment of Depression in Huntington's Disease: A Systematic Review

Depression is a common psychiatric disorder among individuals with Huntington's disease (HD). Depression in HD and major depressive disorder appear to have different pathophysiological mechanisms. Despite the unique pathophysiology, the treatment of depression in HD is based on data from the treatment of major depressive disorder in the general population. The objective of this systematic review was to conduct a comprehensive evaluation of the available evidence. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Studies on the treatment of depression in HD were identified by searching MEDLINE, Embase, and PsycInfo. The initial search yielded 2,771 records, 41 of which were ultimately included. There were 19 case reports, seven case series, three cross-sectional studies, one qualitative study, nine nonrandomized studies, and two randomized trials among the included studies. The most common assessment tools were the Hospital Anxiety and Depression Scale (N=8), the Beck Depression Inventory (N=6), and the Hamilton Depression Rating Scale (N=6). Only 59% of the included studies assessed depressive symptoms with a scoring system. The pharmacological options for the treatment of depression included antidepressants and antipsychotics. Nonpharmacological approaches were multidisciplinary rehabilitation, psychotherapy, and neurostimulation. Limited evidence on the treatment of depression in HD was available, and this literature consisted mainly of case reports and case series. This systematic review highlights the knowledge gap and the pressing need for HD-specific research to determine the efficacy of treatment approaches for depression in HD.

Obsessive-compulsive and perseverative behaviors in Huntington's disease

Obsessive-compulsive and perseverative behaviors (OCBs/PBs) are characteristic features of Huntington's Disease (HD). Although a few recent research have attempted to discriminate between OCBs and PBs, most of the available evidence on OCBs does not consistently make this distinction. In this article, we aimed to explore the current inconsistencies in assessing and reporting OCBs/PBs and map the body of existing evidence. Up to half of the patients with motor manifest HD can experience OCBs. Separate reporting of PBs in HD patients has been uncommon among the studies and was frequently reported as a part of obsessive-compulsive symptoms. The structural limitation of the currently used rating scales and the overlaps in neuropathology and definition of OCBs and PBs are among the main reasons for the mixed reporting of OCBs/PBs. Perseverative thinking or behavior as a separate item is found in a few assessment tools, such as the Problem Behaviors Assessment - Short form (PBA-s). Even when the item exists, it is commonly reported as a composite score in combination with the obsessive-compulsive item. In addition to the significant psychological burden in individuals with HD, PBs are associated with somatic effects (e.g., cardiovascular symptoms) and high-risk behaviors (e.g., suicide). Recognition and monitoring of PBs in HD can aid in early detection of concerning symptoms and differentiating overlapping illnesses.

Frequency and Pathophysiology of Apathy in Huntington Disease: A Systematic Review and Meta-Analysis

OBJECTIVE

Apathy is a common behavioral symptom of Huntington disease (HD). This systematic review describes current evidence on the pathophysiology, assessment, and frequency of apathy in HD.

METHODS

This systematic review was conducted in accordance with PRISMA guidelines. Using a comprehensive search strategy, the investigators searched the MEDLINE, Embase, and PsycINFO databases. All studies that evaluated apathy in HD patients with a valid scale and reported apathy frequency or scores were included. Apathy scores were analyzed by mean or standardized mean differences in accordance with Cochrane guidelines.

RESULTS

A total of 1,085 records were screened and 80 studies were ultimately included. The Problem Behaviors Assessment-Short was the most frequently used apathy assessment tool. Apathy frequency generally ranged from 10%-33% in premanifest HD to 24%-76% in manifest HD. A meta-analysis of 5,311 records of patients with premanifest HD showed significantly higher apathy scores, with a standardized mean difference of 0.41 (CI=0.29-0.52; p<0.001). A comparison of 1,247 patients showed significantly higher apathy scores in manifest than premanifest HD, with a mean difference of 1.87 (CI=1.48-2.26; p<0.001). There was evidence of involvement of various cortical and subcortical brain regions in HD patients with apathy.

CONCLUSIONS

Apathy was more frequent among individuals with premanifest HD compared with those in a control group and among individuals with manifest HD compared with those with premanifest HD. Considering the complexity and unique pattern of development in neurodegenerative disease, further studies are required to explore the pathophysiology of apathy in HD.

The impact of data quality assurance and control solutions on the completeness, accuracy, and consistency of data in a national spinal cord injury registry of Iran (NSCIR-IR)

STUDY DESIGN

Descriptive study.

OBJECTIVE

This study aimed to develop and evaluate a systematic arrangement for improvement and monitoring of data quality of the National Spinal Cord (and Column) Injury Registry of Iran (NSCIR-IR)-a multicenter hospital-based registry.

SETTING

SCI community in Iran.

METHODS

Quality assurance and quality control were the primary objectives in improving overall quality of data that were considered in designing a paper-based and computerized case report. To prevent incorrect data entry, we implemented several validation algorithms, including 70 semantic rules, 18 syntactic rules, seven temporal rules, and 13 rules for acceptable value range. Qualified and trained staff members were also employed to review and identify any defect, inaccuracy, or inconsistency in the data to improve data quality. A set of functions were implemented in the software to cross-validate, and feedback on data was provided by reviewers and registrars.

RESULTS

Socio-demographic data items were 100% complete, except for national ID and education level, which were 97% and 92.3% complete, respectively. Completeness of admission data and emergency medical services data were 100% except for arrival and transfer time (99.4%) and oxygen saturation (48.9%). Evaluation of data received from two centers located in Tehran proved to be 100% accurate following validation by quality reviewers. All data was also found to be 100% consistent.

CONCLUSIONS

This approach to quality assurance and consistency validation proved to be effective. Our solutions resulted in a significant decrease in the number of missing data.

National Guidelines for Cognitive Assessment and Rehabilitation of Iranian Traumatic Brain Injury Patients

BACKGROUND

Individuals with moderate to severe traumatic brain injury (TBI) often have prolonged cognitive impairments, resulting in long-term problems with their real-life activities. Given the urgent need for evidence-based recommendations for neuropsychological management of Iranian TBI patients, the current work aimed to adapt eligible international guidelines for cognitive assessment and rehabilitation of the TBI patients in Iran.

METHODS

The project was led by an executive committee, under the supervision of the Iranian Ministry of Health and Medical Education (MOHME). Following a systematic literature search and selection process, four guidelines were included for adaptation. Clinical recommendations of the source guidelines were tabulated as possible clinical scenarios for 90 PICO clinical questions covering all relevant phases of care. After summing up the scenarios, our initial list of recommendations was drafted according to the Iranian patients' conditions. The final decision-making, with the contribution of a national interdisciplinary panel of 37 experts from across the country, was conducted in two rounds using online and offline survey forms (Round 1), and face-to-face and telephone meetings (Round 2).

RESULTS

A total of 63 recommendations in six sections were included in the final list of recommendations, among which 24 were considered as key recommendations. In addition, some of the recommendations were identified as fundamental, meaning that proper implementation of the other recommendations is largely dependent on their implementation.

CONCLUSION

Iranian health policy makers and rehabilitation program managers are recommended to address some fundamental issues to provide the necessary infrastructure to set up an efficient cognitive rehabilitation service system.

Volume Changes After Traumatic Spinal Cord Injury in Animal Studies-A Systematic Review

Abstract- There are limited data on the lesion volume changes following spinal cord injury (SCI). In this study, a meta-analysis was performed to evaluate the volume size changes of the injured spinal cord over time among animal studies in traumatic SCI. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a comprehensive electronic search of English literature of PubMed and EMBASE databases from 1946 to 2015 concerning the time-dependent changes in the volume of the spinal cord following mechanical traumatic SCI. A hand-search was also performed for non-interventional, non-molecular, and non-review studies. Quality appraisal, data extraction, qualitative and quantitative analyses were performed afterward. Of 11,561 articles yielded from electronic search, 49 articles were assessed for eligibility after reviewing of titles, abstracts, and references. Ultimately, 11 articles were eligible for quantitative synthesis. The ratio of lesion volume to spinal cord total volume increased over time. Avascularity appeared in spinal cord 4 hours after injury. During the first week, the spinal subarachnoid space decreased. The hemorrhagic lesion size peaked in 1 week and decreased thereafter. Significant loss of gray and white matter occurred from day 3 with a slower progression of white matter damage. Changes of lesion extent over time is critical in pathophysiologic processes after SCI. Early avascularity, rapid loss of gray matter, slow progression of white matter damage, and late cavitation are the pathophysiologic key points of SCI, which could be helpful in choosing the proper intervention on a timely basis.

Reliability and Validity of the AOSpine Thoracolumbar Injury Classification System: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

The AOSpine thoracolumbar injury classification system (ATLICS) is a relatively simple yet comprehensive classification of spine injuries introduced in 2013. This systematic review summarizes the evidence on measurement properties of this new classification, particularly the reliability and validity of the main morphologic injury types with and without inclusion of the subtypes.

METHODS

A literature search was performed using PubMed and Embase in September 2016. A revised version of the COSMIN checklist was used for evaluation of the quality of studies. Two independent reviewers performed all steps of the review.

RESULTS

Nine articles were included in the final review, all of which evaluated the reliability of the ATLICS and had a fair methodological quality. The reliability of the modifiers was unknown. Overall, the quality of evidence for reliability of the morphologic and neurologic classification sections was low. However, there was moderate evidence for poor interobserver reliability of the morphologic classification when all subtypes were included, and moderate evidence for good intraobserver reliability with exclusion of subtypes. The reliability of the morphologic classification was independent of the observer's experience and cultural background.

CONCLUSIONS

ATLICS represents the most current system for evaluation of thoracolumbar injuries. Based on this review, further studies with robust methodological quality are needed to evaluate the measurement properties of ATLICS. Shortcomings of the reliability studies are discussed.

Axonal degeneration and demyelination following traumatic spinal cord injury: A systematic review and meta-analysis

The pathophysiology of spinal cord injury (SCI) related processes of axonal degeneration and demyelination are poorly understood. The present systematic review and meta-analysis were performed such to establish quantitative results of animal studies regarding the role of injury severity, SCI models and level of injury on the pathophysiology of axon and myelin sheath degeneration. 39 related articles were included in the analysis. The compiled data showed that the total number of axons, number of myelinated axons, myelin sheath thickness, axonal conduction velocity, and internode length steadily decreased as time elapsed from the injury (P_{for trend}<0.0001). The rate of axonal retrograde degeneration was affected by SCI model and severity of the injury. Axonal degeneration was higher in injuries of the thoracic region. The SCI model and the site of the injury also affected axonal retrograde degeneration. The number of myelinated axons in the caudal region of the injury was significantly higher than the lesion site and the rostral region. The findings of the present meta-analysis show that the pathophysiology of axons and myelin sheath differ in various phases of SCI and are affected by multiple factors related to the injury.

Biofunctionalized peptide-based hydrogel as an injectable scaffold for BDNF delivery can improve regeneration after spinal cord injury

BACKGROUND

The complex pathophysiological events occurring after traumatic spinal cord injuries (TSCI) make this devastating trauma still incurable. Peptide amphiphile (PA) hydrogels are nanobiomaterials displaying desirable properties for application in regenerative medicine because they are absorbable, injectable, allowing biofunctionalization, controlling release of trophic factors and mimic extracellular matrix (ECM). In this study, we explored the potentiality of the IKVAV-functionalized PA hydrogel to provide a permissive environment for cell migration and growth as well as sustained release of BDNF at the lesion after severe compression injury model.

METHODS

The IKVAV-functionalized PA was synthesized by automated solid-phase approach and its secondary structure was evaluated by Circular dichroism (CD) spectroscopy. The potential of IKVAV-functionalized PA to self-assemble into nanofibers and hydrogel formation were assessed using transmission electron microscopy (TEM). Release profiles of BDNF from hydrogel and the bioactivity of the released BDNF from hydrogel were determined using ELISA and DRG bioassay, respectively. Severe spinal cord injury was induced using clip compression at T7-T8 vertebral segment. Twenty four hours post-injury the animals were treated by either IKVAV PA hydrogel, BDNF-loaded IKVAV PA hydrogel, BDNF solution or saline. Two and six weeks later, animals were sacrificed and the lesion site was evaluated based on GFAP, CD68 and ß III tubulin immunoreactivity. Also, locomotor recovery was assessed during 6 weeks using Basso, Beattie, Bresnahan (BBB) scoring test.

RESULTS

The IKVAV PA arranged into nanofibrous structure and provided a sustained release of BDNF over 21 days while preserved the bioactivity of BDNF. Also, BDNF loading influenced the hydrogel nanostructure resulting in aligned orientation of nanofibers. Injection of BDNF-loaded IKVAV PA hydrogel resulted in a considerable axon preservation and astrogliosis reduction at 6 weeks post-injury without showing any inflammatory reaction. However, the BBB score was not statistically different between different treatment groups.

CONCLUSION

Although the locomotor functional recovery was not observed in this study, the axon preservation and minimal inflammation in animals treated with BDNF-incorporated hydrogel indicate the potentiality of the designed intervention for further evaluations in the path of developing efficient therapies for severe spinal cord injury.

Corticosteroid Administration to Prevent Complications of Anterior Cervical Spine Fusion: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

Anterior cervical approach is associated with complications such as dysphagia and airway compromise. In this study, we aimed to systematically review the literature on the efficacy and safety of corticosteroid administration as a preventive measure of such complications in anterior cervical spine surgery with fusion.

METHODS

Following a systematic literature search of MEDLINE, Embase, and Cochrane databases in July 2016, all comparative human studies that evaluated the effect of steroids for prevention of complications in anterior cervical spine surgery with fusion were included, irrespective of number of levels and language. Risk of bias was assessed using MINORS (Methodological Index for Non-Randomized Studies) checklist and Cochrane Back and Neck group recommendations, for nonrandomized and randomized studies, respectively.

RESULTS

Our search yielded 556 articles, of which 9 studies (7 randomized controlled trials and 2 non-randomized controlled trials) were included in the final review. Dysphagia was the most commonly evaluated complication, and in most studies, its severity or incidence was significantly lower in the steroid group. Although prevertebral soft tissue swelling was less commonly assessed, the results were generally in favor of steroid use. The evidence for airway compromise and length of hospitalization was inconclusive. Steroid-related complications were rare, and in both studies that evaluated the fusion rate, it was comparable between steroid and control groups in long-term follow-up.

CONCLUSIONS

Current literature supports the use of steroids for prevention of complications in anterior cervical spine surgery with fusion. However, evidence is limited by substantial risk of bias and small number of studies reporting key outcomes.

Epidemiology of Joint Dislocations and Ligamentous/Tendinous Injuries among 2,700 Patients: Five-year Trend of a Tertiary Center in Iran

BACKGROUND

The epidemiology of traumatic dislocations and ligamentous/tendinous injuries is poorly understood. In this study, we aimed to evaluate the prevalence and distribution of various dislocations and ligamentous/tendinous injuries in a tertiary orthopedic hospital in Iran.

METHODS

Musculoskeletal injuries in an academic tertiary health care center in Tehran February 2005 to October 2010 were recorded. The demographic details of patients with pure dislocations and ligamentous/tendinous injuries were extracted and the type and site of injuries were classified according to their specific age/gender groups.

RESULTS

Among 18,890 admitted patients, 628 (3.3%) were diagnosed with dislocations and 2.081 (11%) with ligamentous/tendinous injuries. The total male/female ratio was 4.2:1 in patients with dislocations and 1.7:1 in patients with ligamentous/tendinous injuries. Shoulder was the most prevalent site of dislocation (50.6%), followed by fingers (10.1%), toes (7.6%), hip (7.3%), and elbow (6.5%). Ankle was the most common site of ligamentous/tendinous injury (53.5%), followed by midfoot (12.3%), knee (8.3%), hand (7%), and shoulder (5%). The mean ages of the patients in dislocations and ligamentous/tendinous injuries were 35.0±18.2 and 31.3± 15.1, respectively. There was no seasonal variation.

CONCLUSION

Shoulder dislocation and ankle ligamentous injury are the most frequent injuries especially in younger population and have different distribution patterns in specific age and sex groups. Epidemiologic studies can help develop and evaluate the injury prevention strategies, resource allocation, and training priorities.

Feasibility and Data Quality of the National Spinal Cord Injury Registry of Iran (NSCIR-IR): A Pilot Study

BACKGROUND

Spinal cord injury (SCI) is one of the most disabling consequences of trauma with unparalleled economic, social, and personal burden. Any attempt aimed at improving quality of care should be based on comprehensive and reliable data. This pilot investigation studied the feasibility of implementing the National Spinal Cord and Column Injury Registry of Iran (NSCIR-IR) and scrutinized the quality of the registered data.

METHODS

From October 2015 to May 2016, over an 8-month period, 65 eligible trauma patients who were admitted to hospitals in three academic centers in mainland Iran were included in this pilot study. Certified registered nurses and neurosurgeons were in charge of data collection, quality verification, and registration.

RESULTS

Sixty-five patients with vertebral column fracture dislocations were registered in the study, of whom 14 (21.5%) patients had evidence of SCI. Mechanisms of injury included mechanical falls in 30 patients (46.2%) and motor vehicle accidents in 29 (44.6%). The case identification rate i.e. clinical and radiographic confirmation of spine and SCI, ranged from 10.0% to 88.9% in different registry centers. The completion rate of all data items was 100%, except for five data elements in patients who could not provide clinical information because of their medical status. Consistency i.e. identification of the same elements by all the registrars, was 100% and accuracy of identification of the same pathology ranged from 66.6% to 100%.

CONCLUSIONS

Our pilot study showed both the feasibility and acceptable data quality of the NSCIR-IR. However, effective and successful implementation of NSCIR-IR data use requires some modifications such as presence of a dedicated registrar in each center, verification of data by a neurosurgeon, and continuous assessment of patients' neurological status and complications.

Clinical Application of Ceramics in Anterior Cervical Discectomy and Fusion: A Review and Update

STUDY DESIGN

Narrative review.

OBJECTIVES

Anterior cervical discectomy and fusion (ACDF) is a reliable procedure, commonly used for cervical degenerative disc disease. For interbody fusions, autograft was the gold standard for decades; however, limited availability and donor site morbidities have led to a constant search for new materials. Clinically, it has been shown that calcium phosphate ceramics, including hydroxyapatite (HA) and tricalcium phosphate (TCP), are effective as osteoconductive materials and bone grafts. In this review, we present the current findings regarding the use of ceramics in ACDF.

METHODS

A review of the relevant literature examining the clinical use of ceramics in anterior cervical discectomy and fusion procedures was conducted using PubMed, OVID and Cochrane.

RESULT

HA, coralline HA, sandwiched HA, TCP, and biphasic calcium phosphate ceramics were used in combination with osteoinductive materials such as bone marrow aspirate and various cages composed of poly-ether-ether-ketone (PEEK), fiber carbon, and titanium. Stand-alone ceramic spacers have been associated with fracture and cracks. Metallic cages such as titanium endure the risk of subsidence and migration. PEEK cages in combination with ceramics were shown to be a suitable substitute for autograft.

CONCLUSION

None of the discussed options has demonstrated clear superiority over others, although direct comparisons are often difficult due to discrepancies in data collection and study methodologies. Future randomized clinical trials are warranted before definitive conclusions can be drawn.

Comparison of Pediatric and General Orthopedic Surgeons' Approaches in Management of Developmental Dysplasia of the Hip and Flexible Flatfoot: the Road to Clinical Consensus

Developmental dysplasia of the hip (DDH) and flatfoot are common pediatric orthopedic disorders, being referred to and managed by both general and pediatric orthopedic surgeons, through various modalities. Our study aimed to evaluate their consensus and perspective disagreements in terms of diagnostic and therapeutic approaches of the mentioned deformities. Forty participants in two groups of general orthopedic surgeons (GOS) (n=20) and pediatric orthopedic surgeons (POS) (n=20), were asked to answer an 8-item questionnaire on DDH and flexible flatfoot. The questions were provided with two- or multiple choices and a single choice was accepted for each one. Chi-square and Fisher's exact tests was performed to compare the responses. For a neonate with limited hip abduction, hip ultrasonography was the agreed-upon approach in both groups (100% POS vs 71% GOS), and for its interpretation 79% of POS relied on their own whereas 73% of GOS relied on radiologist's report (P=0.002). In failure of a 3-week application of the Pavlik harness, ending it and closed reduction (57% POS vs. 41% GOS) followed by surgery quality assessment with CT scan (64% POS vs. 47% GOS) and without the necessity for avascular necrosis evaluation (79% POS vs. 73% GOS) were the choice measures. In case of closed reduction failure, open reduction via medial approach was the favorite next step in both groups (62% POS and 80% GOS). For the patient with flexible flat foot, reassurance was the choice plan of 79% of pediatric orthopedists. Our findings demonstrated significant disagreements among the orthopedic surgeons. This proposes insufficiency of high-level evidence.

Adaptation of Traumatic Brain Injury Guidelines in Iran

CONTEXT

The National institute for health and care excellence (NICE) and scottish intercollegiate guidelines network (SIGN) are two well-known sources of clinical guideline development. In the past years, they have developed clinical guidelines for the management of head injury. In this report, we will highlight our modifications to these guidelines according to the domestic situation in a developing country.

EVIDENCE ACQUISITION

The guidelines were appraised using the appraisal of guidelines for research and evaluation (AGREE) instrument. All key recommendations were reviewed by 14 prominent Iranian neurosurgeons; levels of evidence were evaluated and items with limited evidence were determined. Available evidence for selected items were reviewed and discussed.

RESULTS

The following items were the most challenging when accounting for the domestic situation in Iran: age as a risk factor for referral, computed tomography scan, the impact of medical comorbidities, pregnancy, consultation, referral to a neurosurgical unit, and teleconsulting and observation before discharge.

CONCLUSIONS

The evidence in the discussed topics was limited and controversial. This report is important because it exposes the current knowledge gap in head trauma studies in Iran.

Subarachnoid Space Transplantation of Schwann and/or Olfactory Ensheathing Cells Following Severe Spinal Cord Injury Fails to Improve Locomotor Recovery in Rats

Treatment of spinal cord injury by exogenous cells has brought both successful and unsuccessful results. Olfactory ensheathing cells and Schwann cells have been widely used for transplantation purposes. In this study, we investigated the effects of these cells on contused spinal cord by introducing cells into subarachnoid space. Fifty thousand Schwann cells or olfactory ensheathing cells or a mixture of both cell types were transplanted one week after a 3-second clip compression injury at T-9 spinal cord level in rats. Starting from the day one of spinal cord injury, animals were assessed for six months by BBB test and then were sacrificed for immunohistochemistry labeling of the spinal cord injury site. There was no locomotor recovery in any of the treatment groups including controls. Immunohistochemistry assessment indicated positive labeling of P75 and S100 markers in the cell-transplanted groups compared with control. Our data suggest that transplantation of Schwann cells and/or olfactory ensheathing cells into the subarachnoid space does not improve motor recovery in severely injured spinal cord, at least with the number of cells transplanted here. This, however, should not be regarded as an essentially negative outcome, and further studies which consider higher densities of cells are required.

A Time Course Study of Different Methods of Extraneural Scar Induction in a Rat Model

Background Extraneural scar formation is a challenging problem in nerve repair. Rodent models of scar induction, with their high regenerative capacity, suffer from lack of comparable similarities with human cases. In this study, we attempted to find a reliable and reproducible method of extraneural scarring with a significant impact on the peripheral nerve function. Methods A total of 60 rats were divided into three scar induction groups: abrasion (with a small piece of compressed steel wool), mincing (with extracorporeal mincing of adductor muscle and a 5-mm wide strip of the anterior border of the biceps femoris), and electrocoagulation (with a bipolar coagulator). Extraneural scarring was evaluated macroscopically and histologically during 8 weeks. The tibial functional index was used for behavioral analysis. Results Among three different physical methods of scar induction that were applied, electrocoagulation had the most functional impairment (p < 0.001, two-way analysis of variance); whereas mincing produced the most adhesive and intensive scar, morphologically (p < 0.001). Conclusion We conclude that: (1) the impact of the extraneural scar on the nerve is morphologically and functionally different, based on the method of scarring; (2) to achieve a scar model comparable to the human situation, a method in which the involved nerve is functionally impaired, is preferred over the ones that merely produce a bulky scar.

Comparison of a new single-donor human fibrin adhesive with suture for posterior tibial nerve repair in rat: biomechanical resistance and functional analysis

OBJECTIVE

The use of fibrin adhesives has a broad background in nerve repair. Currently the suboptimal physical properties of single- donor fibrin adhesives have restricted their usage. The present experiment studies the performance and physical characteristics of a modified fibrin glue prepared from single-donor human plasma in the repair of posterior tibial nerve of rat.

METHODS

Forty Wistar rats were divided into 5 groups; in the control group, tibial nerve was completely transected and no treatment was done, while in the four experimental groups the nerve stumps were reconnected by one suture, three sutures, one suture with fibrin glue and fibrin glue alone respectively. During 8 weeks of follow-up, Tibial Function Index was measured weekly and adhesive strength, inflammation and scar formation were assessed at the end of the study.

RESULTS

Nerve stumps dehiscence rate and adhesive strength were similar in all experimental groups and significantly differed from control group (P<0.05). By the end of the eighth follow-up week, functional recovery of one and three sutures groups were significantly higher than groups in which fibrin glue was used for repair (P<0.05). The amount of inflammation and scar tissue formation was similar among all groups.

CONCLUSION

The study results show that the prepared single-donor fibrin adhesive has acceptable mechanical properties which could provide required adhesiveness and hold nerve stumps in the long term; yet, we acknowledge that more studies are needed to improve functional outcome of single donor fibrin adhesive repair.

Two-Stage Nerve Graft in Severe Scar: A Time-Course Study in a Rat Model

BACKGROUND

Peripheral nerve repair outcomes are suboptimal in the presence of severe soft tissue injury and excessive scarring paralleling the process in tendon reconstruction of the hand. Inspired by the advantages of the two-stage technique in tendon grafting and with encouraging preliminary results, we aimed to investigate the two-stage nerve grafting technique as an alternative method of secondary nerve repair.

METHODS

Thirty female rats (~200 g) were randomly distributed into two groups (n=15). A 15 mm gap was created in the sciatic nerve of the animals and an excessive extraneural scar was induced using the "mincing" method. In this method, a thin strip of muscle was removed, minced in a petri dish and returned to the peripheral nerve. In the two-stage nerve graft group, a silicone tube was interposed in the first stage. After 4 weeks, in the second stage, the silicone tube was removed and a median nerve autograft was interposed through the newly formed vascularized sheath. In the conventional graft group, two nerve ends were protected with silicone caps in the first stage. After 4 weeks the caps were removed and the median graft was interposed. Behavioral assessments were performed at week 15 after surgery with the withdrawal reflex latency (WRL) and extensor postural thrust (EPT) and at the 3, 6 and 15-week time points with the TOA (toe out angle). Masson Trichrome staining method was used for histological assessments at week 15.

RESULTS

According to the EPT and WRL, the two-stage nerve graft showed significant improvement (P=0.020 and P=0.017 respectively). The TOA showed no significant difference between the two groups. The total vascular index was significantly higher in the two-stage nerve graft group (P<0.001).

CONCLUSIONS

Two-stage nerve graft using a silicone tube enhances vascularity of the graft and improves functional recovery.

The effect of timing of decompression on neurologic recovery and histopathologic findings after spinal cord compression in a rat model

Prior animal models have shown that rats sustaining 3-second immediate spinal cord compression had significantly better functional recovery and smaller lesion volumes than rats subjected to compression times of 1 hour, 6 hours, 3 weeks, and 10 weeks after spinal cord injury. We compare locomotor rating scales and spinal cord histopathology after 3 seconds and 10 minute compression times. . Ten rats were assigned into two early (3-second) and late (10-minute) compressive surgery groups. Compressive injury was produced using an aneurysmal clip method. Rats were followed-up for 11 weeks, and behavioral assessment was done by inclined plane test and tail-flick reflex. At the end of the study, the rats were sacrificed, and spinal cord specimens were studied in light and EM. Basso, Beattie and Bresnahan (BBB) locomotor rating scales were significantly better in the early compression group after the 4th week of evaluation (P&lt;0.05) and persisted throughout the remainder of the study. Histopathology demonstrated decreased normal tissue, more severe gliosis and cystic formation in the late group compared to the early group (P&lt;0.05). In EM study, injuries in the late group including injury to the myelin and axon were more severe than the early compression group, and there was more cytoplasmic edema in the late compression group. Spinal cord injury secondary to 3-second compression improves functional motor recovery, spares more functional tissue, and is associated with less intracellular edema, less myelin and axon damage and more myelin regeneration in rats compared to those with 10 minutes of compression. Inclined plane test and tail-flick reflex had no significant difference.

Does preservation of active range of motion after acute elbow injury rule out the need for radiography?

BACKGROUND

We aimed to evaluate the role of a normal elbow active range of motion (ROM) in predicting low fracture risk and avoiding elbow X-ray in patients with acute elbow injuries. Lack of any approved rules for this purpose led us to evaluate simple physical examination methods to predict elbow fractures.

METHODS

In this observational study, all patients with elbow injury who presented to two emergency departments were enrolled according to specific criteria. Patients were examined by emergency or orthopedics residents. Elbow radiographs were reviewed by a radiologist for fractures and soft tissue injuries. Results of the clinical examination and radiographs were recorded for statistical analysis. Sensitivity, specificity and positive and negative predictive values were calculated.

RESULTS

Elbow fractures were identified in 10 of the 102 enrolled patients (9.8%). Nine of the 10 had limited ROM in all movements. Limited active elbow ROM in predicting elbow fracture revealed a sensitivity of 90%, specificity of 92%, and positive and negative predictive values of 56% and 98%, respectively. Individuals with limitation in one or two directions had no signs of fracture in the X-rays.

CONCLUSION

Patients with elbow injury and a limited ROM in all directions of flexion, extension, supination and pronation require further X-ray investigations.

The effect of timing of decompression on neurologic recovery and histopathologic findings after spinal cord compression in a rat model

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Effects of brain contusion on mild traumatic brain injured patients

Background:

Traumatic brain injury (TBI) is an important health issue with high prevalence worldwide. The most common type of TBI is mild traumatic brain injury (MTBI). MTBI is defined as a condition with self-limited symptoms; however it could cause some structural abnormalities in brain and become more complicated. Visible structural brain damage could have an important effect on post- MTBI recovery, but the outcome is not yet fully understood. Therefore, the present study aims to investigate the clinical course of MTBI patients whose computed tomography (CT) scans showed the presence of contusion.

Methods:

Fifty patients with MTBI and simultaneous brain contusion in their CT scans were enrolled according to specific exclusion criteria and studied for 14 months. The patients were followed up for two weeks after their admission for neurosurgical interventions, decreased level of consciousness and other neurological complications.

Results:

The presence of neurological symptoms increased the length of hospital stay and number of CT scans. Forty-two percent of MTBI patients with contusion did not have any objective neurological signs. Fifty percent returned later to the hospital with neurologic symptoms and signs. The most leading causes of the MTBI were post seizure headache and dizziness. Rehospitalization was increased in the patients with altered level of consciousness. The size of brain contusion increased in two patients without further need for neurosurgical intervention.

Conclusions:

Contusion alone did not worsen the prognosis of patients in short term follow up and did not cause neurosurgical interventions.

Keywords:

Mild traumatic brain injury, Contusion, Computed tomography, Outcome, Rehospitalization

Effects of brain contusion on mild traumatic brain-injured patients

Traumatic brain injury (TBI) is an important health issue with high prevalence. The most common type of TBI is mild TBI (MTBI). MTBI is known as a condition with self-limited symptoms; however, it could cause some structural abnormalities of brain and become complicated. Visible structural brain damage could have an important effect on recovery after MTBI, but the outcome is not fully understood. This study investigated the clinical course of MTBI patients with the existence of contusion in computed tomography (CT) imaging. Fifty patients with MTBI and simultaneous brain contusion in CT scan were enrolled according to specific exclusion criteria in 14 month. Patients were followed up for two weeks after their first arrival for neurosurgical interventions, decreased level of consciousness, and other neurological complications. Presence of neurological symptoms increased duration of hospital stay and number of CT scans. Forty-two percent of MTBI patients with contusion did not have any objective neurological signs. Fifty percent returned to the hospital with neurologic symptoms and signs. Leading causes were headache followed by seizure and dizziness. Rehospitalization was increased in the patients with altered level of consciousness. The size of brain contusion increased in two patients without further need for neurosurgical intervention. Contusion alone did not worsen the prognosis of patients in short-term follow-up and did not cause neurosurgical interventions.