Outcome of patients after lower limb fracture with partial weight bearing postoperatively treated with or without anti-gravity treadmill (alter G®) during six weeks of rehabilitation - a protocol of a prospective randomized trial

Background

Partial or complete immobilization leads to different adjustment processes like higher risk of muscle atrophy or a decrease of general performance. The present study is designed to prove efficacy of the anti-gravity treadmill (alter G®) compared to a standard rehabilitation protocol in patients with tibial plateau (group 1)or ankle fractures (group 2) with six weeks of partial weight bearing of 20 kg.

Methods and Design

This prospective randomized study will include a total of 60 patients for each group according to predefined inclusion and exclusion criteria. 1:1 randomization will be performed centrally via fax supported by the Clinical Trial Centre Leipzig (ZKS Leipzig). Patients in the treatment arm will be treated with an anti-gravity treadmill (alter G®) instead of physiotherapy. The protocol is designed parallel to standard physiotherapy with a frequency of two to three times of training with the treadmill per week with duration of 20 min for six weeks.

Discussion

Up to date no published randomized controlled trial with an anti-gravity treadmill is available. The findings of this study can help to modify rehabilitation of patients with partial weight bearing due to their injury or postoperative protocol. It will deliver interesting results if an anti-gravity treadmill is useful in rehabilitation in those patients. Further ongoing studies will identify different indications for an anti-gravity treadmill. Thus, in connection with those studies, a more valid statement regarding safety and efficacy is possible.

Trial registration

NCT02790229 registered on May 29, 2016

[Acute pain management in proximal femoral fractures: femoral nerve block (catheter technique) vs. systemic pain therapy using a clinic internal organisation model]

BACKGROUND

The aim of this study was to compare safety and efficacy of catheter-mediated femoral nerve block analgesia with systemic pain therapy in patients with proximal femoral fractures in the pre-operative and post-operative setting using a protocol for coordinating pain management.

METHODS

In a prospective randomised trial of patients attending the emergency department, 100 individuals were selected with a clinically diagnosed proximal femoral fracture. Patients were divided into two equal groups A and B. Group A (n=50) received a catheter-mediated femoral nerve block with 1% prilocaine (40 ml) and post-operatively 0.2% ropivacaine (30 ml) 6 hourly. Group B (n=50) initially received intravenous metamizol (1 g) and a fixed combination of oral tilidine (100 mg) + naloxone (8 mg). Patients aged 90 years or more received a reduced dose (tilidine 75 mg + naloxone 6 mg). In the post-operative period regular oral ibuprofen (400 mg, 8 hourly) in addition to oral tilidine (50 mg) + naloxone (4 mg) was given as required for break through pain. Pain intensity was measured using a verbal rating scale (VRS) from 1 to 5: pain free (=1), mild pain (=2), moderate pain (=3), severe pain (=4), excruciating pain (=5). Pain scores were recorded at rest (R), during passive anteflection (30 degrees) of the hip (PA) on arrival and at 15 and 30 min after initial administration of analgesia. Thereafter, recordings were made 4 times a day up to the third post-operative day.

RESULTS

Pain scores were comparable for both groups on admission (VRS in R 2.50 vs. 2.46; VRS during PA 4.30 vs. 4.34). Significant pain relief was achieved in both groups following initial administration of analgesia, but the total pain scores in group A were significantly lower than in group B (VRS in R 1.22 vs. 1.58, p<0.01 and VRS during PA 2.66 vs. 3.26; p<0.001). No difference was noted between the two groups during the first 3 post-operative days. No severe complications occurred as a result of analgesia, however, the catheter was dislodged in 20% of patients in group A resulting in the need for systemically administered analgesia.

CONCLUSION

All patients presenting with proximal femoral fractures should receive adequate analgesia within the emergency department even prior to radiographic imaging. Femoral nerve block should be considered as the method of choice. The insertion of a femoral nerve block catheter has the dual advantage of early analgesia permitting repeated clinical examination in addition to continued post-operative pain management. The cumbersome logistics inherent in this technique within the clinical setting limits its practical application. An initial single-shot regional nerve block followed by a systemic post-operative analgesia protocol was considered an appropriate alternative. The execution of safe, consistent and appropriate regional nerve block anaesthesia is reliant on formal guidelines and protocols as agreed by the multidisciplinary teams involved with patient-directed pain management and good clinical practice.

A less invasive posterior approach for the management of extended secondary epidural abscess technical note

Spondylodiscitis is considered to be the main cause of epidural abscess. In this report, the authors present their concept for the management of the extended epidural abscess that occurs in combination with spondylodiscitis. It consists of debridement and fusion for spondylodiscitis together with epidural abscess drainage using a microscopically assisted percutaneous technique. In the period from April 2000 to April 2004, 5 patients with spondylodiscitis and an accompanying extended epidural abscess were operated on. The mean age of the patients was 66 years. There were 4 males and one female. The follow-up period ranged from 3-12 months. To manage the extended epidural abscess, the authors created one or two drainage sites along the extension of epidural abscess. These drainage sites were made using a microscopically assisted percutaneous approach. In all presented cases, the offending organism was Staphylococcus aureus. The postoperative infection markers showed marked regression. The postoperative control MRI demonstrated effective drainage of the extended epidural abscess. Regarding the neurological deficits, 3 patients previously classified as Frankel C showed an improvement to Frankel E within 3 months postoperatively. From these results, it seems that our technique (ventro-dorsal abscess drainage combined with a microscopically assisted percutaneous approach) could be a successful method for the management of the extended epidural abscess associated with spondylodiscitis.

Traumatic subdural hematoma of the thoraco-lumbar junction of spinal cord

BACKGROUND

Spinal subdural hematoma (SSDH) is an exceedingly uncommon and potentially neurologically devastating condition. Recognition of blood products in magnetic resonance imaging is a very important clue for the diagnosis of SSDH. It is generally agreed that prompt surgical evacuation should be performed before irreversible damage to the spinal cord occurs. However, conservative treatment still plays a role in the management of SSDH.

OBJECTIVES

To describe the clinical presentation, characteristic MRI findings, and treatment of traumatic SSDH.

METHODS

A case of traumatic SSDH at the thoraco-lumbar junction.

RESULTS

Magnetic resonance imaging findings of high signal intensity lesion in both T1 and T2 sequences suggest the possibility of subdural hematoma although it may be mistaken for tumorlike cystic lesion of the cord. Although there is a place for conservative treatment of subdural hematoma, we believe that rapid surgical drainage of the subdural hematoma will be associated with the best prognosis especially in the cervical, thoracic, and thoraco-lumbar junctions of the spinal cord.

CONCLUSIONS

Rapid surgical drainage of traumatic SSDH affecting the thoraco-lumbar junction of the cord will be associated in most of the cases with rapid neurologic recovery.

The influence of fracture mechanism and morphology on the reliability and validity of two novel thoracolumbar injury classification systems

STUDY DESIGN

The Thoracolumbar Injury Severity Score (TLISS) and the Thoracolumbar Injury Classification and Severity Score (TLICS) were prospectively evaluated.

OBJECTIVES

To compare the reliability and validity of the TLISS and TLICS schemes to determine the importance of injury mechanism and morphology to the identification and treatment of thoracolumbar fractures.

SUMMARY OF BACKGROUND DATA

Two novel algorithms have been developed for the categorization and management of thoracolumbar injuries: the TLISS system emphasizing injury mechanism and the TLICS scheme involving injury morphology.

METHODS

The clinical and radiographic findings of 25 patients with thoracolumbar fractures were prospectively presented to 5 groups of surgeons with disparate levels of training and experience with spinal trauma. These injuries were consecutively scored, first using the TLISS and then 3 months later with the TLICS. The recommended treatments proposed by the 2 schemes were compared with the actual management of each patient.

RESULTS

For both algorithms, the interrater kappa statistics of all subgroups (mechanism/morphology, status of the posterior ligaments, total score, predicted management) were within the range of moderate to substantial reproducibility (0.45-0.74), and there were no statistically significant differences noted between the respective kappa values. Interrater correlation was higher for the TLISS paradigm on mechanism/morphology, integrity of the posterior ligaments, and proposed management (P < or = 0.01). The TLISS and TLICS schemes both exhibited excellent overall validity.

CONCLUSIONS

Although both schemes were noted to have substantial reproducibility and validity, our results indicate the TLISS is more reliable than the TLICS, suggesting that the mechanism of trauma may be a more valuable parameter than fracture morphology for the classification and treatment thoracolumbar injuries. Since these injury characteristics are interrelated and are critical to the maintenance of spinal stability, we think that both concepts should be considered during the assessment and management of these patients.

Clinical performance of a new medullary humeral nail: antegrade versus retrograde insertion

OBJECTIVE

A new intramedullary nail system for humeral shaft fractures is evaluated to determine whether retrograde nailing is as reliable as antegrade nailing.

STUDY DESIGN

Prospective multicenter nonrandomized clinical study.

PATIENTS

Eighty-four patients with acute humeral shaft fractures were nailed with the new unreamed humeral nail (UHN) system. Fifty-seven nails were introduced retrogradely, and twenty-seven antegradely. Bone healing and functional outcome were the follow-up parameters.

RESULTS

The ratio of perioperative complications was equivalent for both groups, but one shaft fracture and three fractures or fissures at the entry point occurred in the group with retrograde nail insertion. Five fractures, all with retrograde nail insertion, needed secondary surgery to achieve bony healing. There was no difference in functional outcome after healing in either group.

CONCLUSION

Retrograde nailing of humeral shaft fractures is technically more demanding than antegrade nailing. Fractures or fissures at the insertion point must be avoided by adequate preparation of the entry hole and careful nail insertion. Bone healing problems seem more surgeon-related than approach-related. As in every other procedure, an optimal fracture configuration and high fracture stability must be achieved.

Clinical performance of a new medullary humeral nail: antegrade versus retrograde insertion

OBJECTIVE

A new intramedullary nail system for humeral shaft fractures is evaluated to determine whether retrograde nailing is as reliable as antegrade nailing.

STUDY DESIGN

Prospective multicenter nonrandomized clinical study.

PATIENTS

Eighty-four patients with acute humeral shaft fractures were nailed with the new unreamed humeral nail (UHN) system. Fifty-seven nails were introduced retrogradely, and twenty-seven antegradely. Bone healing and functional outcome were the follow-up parameters.

RESULTS

The ratio of perioperative complications was equivalent for both groups, but one shaft fracture and three fractures or fissures at the entry point occurred in the group with retrograde nail insertion. Five fractures, all with retrograde nail insertion, needed secondary surgery to achieve bony healing. There was no difference in functional outcome after healing in either group.

CONCLUSION

Retrograde nailing of humeral shaft fractures is technically more demanding than antegrade nailing. Fractures or fissures at the insertion point must be avoided by adequate preparation of the entry hole and careful nail insertion. Bone healing problems seem more surgeon-related than approach-related. As in every other procedure, an optimal fracture configuration and high fracture stability must be achieved.

[Case report on management of grade 4 infected open comminuted tarsus fracture by tibio-Chopart arthrodesis]

We report on the treatment of a 39 year old patient who suffered from subtotal amputation of the middle foot area after fall from tall height. He was treated by an arthrodesis between ventral tibia and distal Chopart-joint which was carried out as late-primary care. Therefore calcaneus and talus were totally and os cuboideum and os scaphoideum were partially removed. This form of arthrodesis is a rare indication. With remaining blood flow and sensibility in the fore foot it is an alternative to amputation/exarticulation in the tibiotalar joint. Advantages are the improved plantar weightbearing area, a simplified supply of orthopedic shoes and a better tactile ground contact.

[Late results of surgical management of medial femoral neck fractures by spongiosa traction screws]

In 36 cases of medial fracture of the femoral neck percutaneous compression osteosynthesis by a specific traction-screw was carried out. During a 3-year follow up five femoral head necroses and three cases of non-union occurred. 28 patients showed good or excellent results. Comparison with results of AO-spongiosa screws and sliding-screw plate reveals no significant differences. Due to small additional operative trauma this percutaneous fixation technique is an appropriate alternative of osteosynthesis of medial fractures of the femoral neck, especially in polytraumatised patients and old patients with high operative risk.

[Effect of hydroxyethyl starch HES 450/0.7 and 5% human albumin on the colloid osmotic pressure and hemodynamic parameters in hypovolemic patients after major abdominal procedures]

In a randomized study 20 patients with hypovolemia following abdominal surgery for malignoma were treated with 500 ml HES 450/0.7 or human albumin 5% during the first 24 h after operation. COP and various blood- and hemodynamic parameters were measured immediately before and after infusion as well as 2, 4 and 6 h after infusion. After HES-infusion COP increased from 20.2 to about 22 mmHg and remained at a significantly higher level (p less than 0.01) for 6 h. After albumin-infusion COP increased from 19.7 to 20.7 mmHg, but already returned to starting level within 2 h. CVP in the HES-group increased from 2.8 to 6.3 cmH2O after infusion, and then gradually dropped to 4 cmH2O during 6 h. In the albumin-group CVP increased from the same starting level only to 4.2 cmH2O, and then dropped back to 3.2 cmH2O after 6 h (no significant difference to the starting level). The other blood- and hemodynamic parameters measured showed no significant differences between the two groups. The results show that a quick and reliable improvement of hypovolemia can be obtained in both groups immediately after infusion, but that the COP- and volume-stabilizing effects of HES-infusion are more distinct and remained for a significantly longer period of time than the effects of albumin 5%-infusion.