Can resistance prehabilitation training bring additional benefits in valvular cardiac surgery? protocol for a randomized controlled trial

INTRODUCTION

Cardiovascular diseases (CVD) are a group of illnesses that include coronary heart disease, cerebrovascular disease, congenital heart disease and deep vein thrombosis. Major surgery is often chosen as the treatment of choice for CVD. The concept of fast-track rehabilitation after surgery appeared in the 1970s. Participation in these exercise-based prehabilitation programmes may decrease postoperative complications and length of hospital stay. The primary aim of the present study is to evaluate whether the implementation of an additional resistance training (RT) prehabilitation protocol within cardiac exercises based prehabilitation can reduce intensive care unit (ICU) length of stay, postoperative complications and hospital length of stay (LOS).

METHODS

A protocol of a prospective, parallel, randomised clinical trial includes 96 adult patients diagnosed with valvular pathology and who have been scheduled for surgery. The participants will be randomly assigned to two groups of 48. Control group will be treated with ventilatory and strengthening of respiratory muscles, and aerobic exercise. Experimental group, in addition, will be treated with RT of peripheral muscles. Both hospital stay and ICU stay will be assessed as main variables. Other secondary variables such as exercise capacity, quality of life and respiratory values will also be assessed. Quantitative variables will be analysed with a T-Test or ANOVA, or Mann Witney if the distribution is non-parametric.

RESULTS AND CONCLUSION

This will be the first controlled clinical study focused on adding strength exercise as an additional treatment during prehabilitation. The results of this study will focus on helping to improve rehabilitation and prehabilitation protocols, considering that it is essential to maintain pulmonary training, as well as the inclusion of peripheral exercises that help people with heart disease to be in a better physical condition in order to increase their participation and sense of quality of life.

Prehabilitation programs in liver resection: a narrative review

BACKGROUND AND OBJECTIVE

Liver resection (LR) is a commonly performed surgical procedure for the management of hepatocellular carcinoma and other liver conditions. Despite its benefits in providing patients a potential cure, it is also associated with significant postoperative complications and prolonged recovery periods. In recent years, pre-operative rehabilitation (prehabilitation) has emerged as an up-and-coming strategy to optimize patients' physical, psychological and functional status before LR, leading to improved surgical and patient postoperative outcomes. Hence, our review aims to explore and synthesize the existing literature on prehabilitation in LR to provide an overview of the current evidence to help guide physicians in managing their patients.

METHODS

A comprehensive literature search was conducted in multiple electronic databases from inception to July 2023. The search strategy was tailored to capture studies investigating the role of prehabilitation in LR, and the factors that contribute to beneficial outcomes in the postoperative period.

KEY CONTENT AND FINDINGS

Prehabilitation programs encompass a multifaceted approach to enhance surgical outcomes and patient well-being. This considers the specific needs of the varying patient populations, such as the elderly, or the cancer ridden. Improving physical fitness, nutritional supplementation and psychological support are the common tenets of prehabilitation. In physical prehabilitation, patients are engaged in intensive physical exercise often by means of a cycle ergometer. Addressing nutritional deficiencies through supplements and dietary interventions is also vital. Psychosocial assessments, advance care planning, music therapy, and progressive relaxation exercises are shown to enhance patient resilience and well-being. In addition, innovative approaches such as optimizing fluid balance, avoiding epidural analgesia, perioperative steroid administration, phosphate correction and branched-chain amino acid supplementation are being explored.

CONCLUSIONS

Prehabilitation is important in optimizing patients before LR and is key in improving postoperative outcomes. Several prehabilitation strategies exist, but no formal consensus exists on patient selection and an ideal program.

Application of Accelerated Rehabilitation Surgery in Gastrointestinal Surgery

Adding timely rehabilitation surgery is an optimized perioperative measure that can reduce physical stress, reduce surgical risks, and postoperative complications and promote the recovery of organ function. Therefore, it is of great value to study its application in gastrointestinal surgery (GS). To this end, this article applies retrospective analysis and statistical methods to conduct targeted investigations and studies on GS patients. The results of the survey showed that 26.7% of patients were effective in ARS and 40% were effective in treatment. Compared with traditional treatment methods, its effective treatment rate is 13.4% higher.

Short- and long-term effects of a cardiac rehabilitation program in patients implanted with a left ventricular assist device

The efficacy of cardiac rehabilitation in heart-failure patients who received a left-ventricular assist device (LVAD) instead of heart transplantation (HTx) is still unclear. This study aims to evaluate whether cardiac rehabilitation is beneficial in LVAD as HTx patients in the short term and whether its effects in LVAD patients persist over time. Twenty-five LVAD patients were evaluated by functional and psychological tests at admission (T0) and discharge (T1) of a 4-week inpatient structured rehabilitation program, and follow-ups 3 (T2), 6 (T3), and 12 months (T4) after discharge. Twenty-five matched HTx patients were also studied from T0 to T1 to compare the improvements in the six-minute walk test (6MWT). The quality-of-life scores substantially improved in LVAD patients and the 6MWT showed the same functional recovery as in HTx patients from T0 to T1. After T1, numerous LVAD patients withdrew from the study. However, the 6MWT outcome increased further from T1 to T3, with a positive trend during the follow-ups. Hemoglobin and the ventilatory performance increased, and the psychological perception of heart-failure symptoms and pain further improved at T2. In conclusion, exercise-based rehabilitation programs provide similar beneficial effects in LVAD and HTx patients, without deterioration in LVAD patients up to 12 months after discharge.

Late Recovery of Parathyroid Function After Total Thyroidectomy: A Case-Control Study

The clinical characteristics of patients with postoperative hypoparathyroidism who recover parathyroid function more than 12 months after surgery have not been studied. We aimed to evaluate whether the intensity of replacement therapy with calcium and calcitriol is related to the late recovery of parathyroid function. We compared the demographic, surgical, pathological, and analytical features of two groups of patients: cases, i. e., late recovery patients (those who recover parathyroid function>1 year after thyroidectomy, n=40), and controls, i. e., patients with permanent hypoparathyroidism (n=260). Replacement therapy with calcium and calcitriol was evaluated at discharge of surgery, 3-6 months, 12 months, and last visit. No significant differences were found in clinical, surgical, pathological, or analytical characteristics between cases and controls. The proportion of cases who required treatment with calcium plus calcitriol at 12 months was significantly lower than that found in controls (p<0.001). Furthermore, daily calcium and calcitriol doses in controls were significantly higher than those in cases at 3-6 months (p=0.014 and p=0.004, respectively) and at 12 months (p<0.001 and p=0.043, respectively). In several models of logistic regression analysis therapy with calcium and calcitriol at 12 months was negatively related to late recovery of parathyroid function. Although delayed recuperation of parathyroid function after total thyroidectomy is uncommon (13%), follow-up beyond 12 months is necessary in patients with postoperative hypoparathyroidism, especially in those whose needs of treatment with Ca and calcitriol are reducing over time.

Exercise tolerance and quality of life in hemodynamically partially improved patients with chronic thromboembolic pulmonary hypertension treated with balloon pulmonary angioplasty

The efficacy of extensive balloon pulmonary angioplasty (BPA) beyond hemodynamic improvement in chronic thromboembolic pulmonary hypertension (CTEPH) patients has been verified. However, the relationship between extensive BPA in CTEPH patients after partial hemodynamic improvement and exercise tolerance or quality of life (QOL) remains unclear. We prospectively enrolled 22 CTEPH patients (66±10 years, females: 59%) when their mean pulmonary artery pressure initially decreased to <30 mmHg during BPA sessions. Hemodynamic and echocardiographic data, cardiopulmonary exercise testing, and QOL scores using the 36-item short form questionnaire (SF-36) were evaluated at enrollment (entry), just after the final BPA session (finish), and at the 6-month follow-up (follow-up). We analyzed whether extensive BPA improves exercise capacity and QOL scores over time. Moreover, the clinical characteristics leading to improvement were elucidated. The peak oxygen uptake (VO₂) showed significant improvement at entry, finish, and follow-up (17.3±5.5, 18.4±5.9, and 18.9±5.3 mL/kg/min, respectively; P<0.001). Regarding the QOL, the physical component summary (PCS) scores significantly improved (32±11, 38±13, and 43±13, respectively; P<0.001), but the mental component summary scores remained unchanged. Linear regression analysis revealed that age and a low peak VO2 at entry were predictors of improvement in peak VO2, while low PCS scores and low TAPSE at entry were predictors of improvement in PCS scores. In conclusion, extensive BPA led to improved exercise tolerance and physical QOL scores, even in CTEPH patients with partially improved hemodynamics.

The effects of early enteral nutrition on mortality after major emergency abdominal surgery: A systematic review and meta-analysis with Trial Sequential Analysis

BACKGROUND

Early oral or enteral nutrition (EEN) has been proven safe, tolerable, and beneficial in elective surgery. In emergency abdominal surgery no consensus exists regarding postoperative nutrition standard regimens. This review aimed to assess the safety and clinical outcomes of EEN compared to standard care after emergency abdominal surgery.

METHODS

The review protocol was performed according to the Cochrane Handbook and reported according to PRISMA. Clinical outcomes included mortality, specific complication rates, length of stay, and serious adverse events. Risk of bias was assessed by Cochrane risk of bias tool and Downs and Black. GRADE assessment of each outcome was performed, and Trial Sequential Analysis was completed to obtain the Required Information Size (RIS) of each outcome.

RESULTS

From a total of 4741 records screened, a total of five randomized controlled trials and two non-randomized controlled trials were included covering 1309 patients. The included studies reported no safety issues regarding the use of EEN. A significant reduction in the mortality rate of EEN compared with standard care was seen (OR 0.59 (CI 95% 0.34-1.00), I² = 0%). Meta-analyses on sepsis and postoperative pulmonary complications showed non-significant tendencies in favor of EEN compared with standard care. GRADE assessment of all outcomes was evaluated 'low' or 'very low'. Trial Sequential Analysis revealed that all outcomes had insufficient RIS to confirm the effects of EEN.

CONCLUSION

EEN after major emergency surgery is correlated with reduced mortality, however, more high-quality data regarding the optimal timing and composition of nutrition are needed before final conclusions regarding the effects of EEN can be made.

Exercise and lung cancer surgery: A systematic review of randomized-controlled trials

Lung cancer patients undergoing surgery are often left physically deconditioned and/or with functional deficits. Exercise interventions may improve pulmonary and physical function before and after lung resection. We conducted a systematic review of randomized-controlled trials (RCTs) testing the impact of pre-, post-, and combined pre-and-post surgery exercise interventions on physical and pulmonary function in lung cancer patients. Exercise pre-surgery seems to substantially improve physical and pulmonary function, which are factors associated with improved ability to undergo surgery while reducing post-surgery complications. Evidence is inconsistent for post-surgery interventions, reporting no or moderate effects. Results from pre-and-post surgery interventions are limited to one study. In conclusion, pre- and post-surgery exercise interventions, individually, have shown beneficial effects for lung cancer patients undergoing surgery. The impact of interventions combining both pre- and post-surgery exercise programs remains unknown. More evidence is needed on the ideal exercise setting, and timing across the lung cancer care continuum.

Chronic Resistance Exercise Improves Functioning and Reduces Toll-Like Receptor Signaling in Elderly Patients With Postoperative Deconditioning

OBJECTIVE

Elderly patients continue to experience low levels of mobility during and following postoperative hospitalization that lead to persistent physical decline. Therefore, here we compared chronic resistance (CR) exercise against chronic aerobic (CA) exercise in ameliorating postoperative functioning and reducing proinflammatory muscular Toll-like receptor (TLR)-associated signaling in elderly postoperative patients.

METHODS

We conducted a prospective, randomized trial comparing the effects of 3 exercise programs (CR, CA, and CR + CA) in 66 elderly patients recovering from recent hip, femur, or pelvic fracture repair surgery. The primary outcomes were changes in anatomic/physical performance parameters (ie, maximal oxygen intake, endurance, quadriceps cross-sectional area, and maximum knee-extensor force). The secondary outcomes were changes in TLR/nuclear factor kappa beta signaling pathway marker expression.

RESULTS

Three of the 4 anatomic/physical performance parameters significantly improved for the CR and CR + CA cohorts. Muscular expression of myeloid differentiation primary response gene 88, transforming growth factor beta-activated kinase 1 (TLR signaling pathway markers), p50, p65, tumor necrosis factor α, and interleukin 6 (nuclear factor kappa beta signaling pathway markers) all showed significant reductions after CR and CR + CA. Serum expression of 2 key TLR4 ligands, heat shock protein 70 and serum amyloid A, also showed significant reductions after CR and CR + CA.

CONCLUSIONS

Three months of CR or CR + CA improves maximal oxygen consumption, quadriceps cross-sectional area, and maximum knee-extensor force while lowering muscular proinflammatory signaling markers in elderly adults with postoperative deconditioning.

An evaluation of the influence of force- and weight bearing (a)symmetry on patient reported outcomes after total knee arthroplasty

It has been reported that balance impairments and asymmetrical movement patterns occur in patients after total kne arthroplasty (TKA). The purpose of this study was to evaluate if force- and weight-bearing asymmetry correlate with patient-reported outcomes (PROMs). Twenty patients were prospectively analysed up to 6 months after TKA. Quadriceps- and hamstring force were measured using a hand-held dynamometer. Vertical ground reaction forces during sit-to-stand, stair descending and squatting were assessed by force plates. Patients were asked to complete the KOOS, OKS and 2011 KSS. The symmetry-ratios during sit-to-stand, squat and stair-descent improved significantly. Preopera-tive quadriceps-force was positively correlated with KOOS-Symptoms (r=0.583, p=0.037). The pre-operative load-symmetry ratio during STS was negatively correlated with improvement in KOOS Pain (r=-0.675, p=0.011) and Symptoms (r=-0.674, p=0.008). In deep flexion, preoperative bodyweight ratio was positively correlated with postoperative OKS (r=0.601, p=0.039), KSS-Satisfaction (r=0.675, p=0.011) and improvement in KSS-Satisfaction (r=0.684, p=0.029). Weight bearing and force asymmetry do exist before TKA and take up to at least 6-months to fully recover. The more symmetry in muscle-force and weight-bearing is found preoperatively, the better the PROMs will be at 6 months after surgery.

The emerging role of hearing loss rehabilitation in patients with vestibular schwannoma treated with Gamma Knife radiosurgery: literature review

Stereotactic radiosurgery (SRS) is currently the most common treatment for small- to medium-size vestibular schwannoma (VS). Despite favorable outcome, hearing deterioration still remains an underestimated problem, and the role of hearing rehabilitation is an underinvestigated topic. Among available technologies, cochlear implant (CI) should represent a valid alternative in sporadic VS with single-sided deafness and in neurofibromatosis (NF2) with bilateral profound hearing loss. A literature review of the current clinical data was performed searching scientific literature databases. From all of the articles found, 16 papers were selected. Forty-four subjects treated with radiosurgery (18 male, 19 female, and in 7 cases, sex were not specified; 43 NF2 and 1 sporadic VS) were included in the analysis. Epidemiological, clinical, tumor, treatment, and audiological data were collected. Clinical outcome at last follow-up showed an audiological improvement in 25 of the 44 patients. The audiological outcome was unchanged in 16 cases. Audiological deterioration was recorded in 3 cases. Severity of NF2 phenotype, long history of ipsilateral profound deafness before implantation, progressive tumor growth, and high radiation dose (20 and 40 Gy) were found in patients with a worst audiological outcome. Hearing rehabilitation can improve audiological results for VS patients following SRS in selected cases. Hearing rehabilitation with cochlear implant (CI) in SSD leads to partial restoration of binaural hearing with an improvement in speech comprehension in noise and in sound localization, and partial suppression of subjective incapacitating tinnitus. SRS followed by CI may represent in selected cases a potential emerging option in the management of these patients, aimed at improving their quality of life. Possible implications for the follow-up of these patients are still present, although partially resolved.

Pelvic floor rehabilitation to improve functional outcome and quality of life after surgery for rectal cancer: study protocol for a randomized controlled trial (FORCE trial)

BACKGROUND

After low anterior resection (LAR), up to 90% of patients develop anorectal dysfunction. Especially fecal incontinence has a major impact on the physical, psychological, social, and emotional functioning of the patient but also on the Dutch National Healthcare budget with more than €2000 spent per patient per year. No standardized treatment is available to help these patients. Common treatment nowadays is focused on symptom relief, consisting of lifestyle advices and pharmacotherapy with bulking agents or antidiarrheal medication. Another possibility is pelvic floor rehabilitation (PFR), which is one of the most important treatments for fecal incontinence in general, with success rates of 50-80%. No strong evidence is available for the use of PFR after LAR. This study aims to prove a beneficial effect of PFR on fecal incontinence, quality of life, and costs in rectal cancer patients after sphincter-saving surgery compared to standard treatment.

METHODS

The FORCE trial is a multicenter, two-armed, randomized clinical trial. All patients that underwent LAR are recruited from the participating hospitals and randomized for either standard treatment or a standardized PFR program. A total of 128 patients should be randomized. Optimal blinding is not possible. Stratification will be done in variable blocks (gender and additional radiotherapy). The primary endpoint is the Wexner incontinence score; secondary endpoints are health-related and fecal-incontinence-related QoL and cost-effectiveness. Baseline measurements take place before randomization. The primary endpoint is measured 3 months after the start of the intervention, with a 1-year follow-up for sustainability research purposes.

DISCUSSION

The results of this study may substantially improve postoperative care for patients with fecal incontinence or anorectal dysfunction after LAR. This section provides insight in the decisions that were made in the organization of this trial.

TRIAL REGISTRATION

Netherlands Trial Registration, NTR5469, registered on 03-09-2015. Protocol FORCE trial V18, 19-09-2019. Sponsor Radboud University Medical Center, Nijmegen.

C5 palsy after C5/6/7 posterior foraminal decompression: A case report

RATIONALE

Although C5 palsy is a common complication of cervical spine surgery, its cause has not been confirmed. There are various hypotheses for its mechanism, including spinal cord impairment and nerve involvement. Therefore, prophylactic foraminotomy is one of the methods recommended for preventing C5 palsy. However, we describe a patient who experienced C5 palsy after microendoscopic foraminotomy between the left C5/6 and C6/7 levels.

PATIENT CONCERNS

A 43-year-old man presented with a 14-month history of progressive numbness in the left upper limb. We performed microendoscopic left foraminal decompressions at the C5/6/7 levels to treat the left C6 and C7 radiculopathy. On the postoperative day 1, we observed weak motor strength of the left deltoid, left biceps, and left forearm pronator, while the motor strength of the other muscles was normal.

DIAGNOSES

C5 palsy following C5/6/7 left foraminotomy.

INTERVENTION

Follow-up rehabilitation with muscle strength training and range of motion training.

OUTCOME

The patient recovered his motor strength completely within 3 months postoperatively.

LESSONS

In this case, the C5 palsy could not be adequately explained by the theory of nerve root impingement or disruption in blood circulation following spinal cord decompression. We hypothesized that the patient had drill heat-induced C5 palsy. Regarding the C5 palsy without C5 nerve root decompression, we hypothesize that the C5 palsy in C5/6/7 foraminotomy could be related to variations in the formation of the brachial plexus. Prophylactic foraminotomy for cervical posterior surgery should be performed with care, limiting its use in patients who are at a risk of developing C5 palsy because the prophylactic procedure can cause C5 palsy. We must also consider that even without decompression at the C4/5 level, there is a possibility of C5 palsy occurring.

Pelvic floor muscle training in radical prostatectomy: a randomized controlled trial of the impacts on pelvic floor muscle function and urinary incontinence

BACKGROUND

Pelvic floor muscle training (PFM) training for post-prostatectomy incontinence (PPI) is an important rehabilitative approach, but the evidence base is still evolving. We developed a novel PFM training program focussed on activating fast and slow twitch muscle fibres. We hypothesized that this training, which commenced pre-operatively, would improve PFM function and reduce PPI, when compared to a control group.

METHODS

This randomized trial allocated 97 men (63 ± 7y, BMI = 25.4, Gleason 7) undergoing radical prostatectomy (RP) to either a control group (n = 47) performing low-volume rehabilitation, or an intervention group (n = 50). Both interventions commenced 5 weeks prior to surgery and continued for 12 weeks post-RP. Participants were assessed pre-operatively and at 2, 6 and 12 weeks post-RP using 24 h pad weights, International Prostate Symptom Score (IPSS), Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP) and real time ultrasound (RTUS) measurements of PFM function.

RESULTS

Following RP, participants in the control group demonstrated a slower return to continence and experienced significantly more leakage (p < 0.05), measured by 24 h pad weight, compared to the intervention group, suggesting an impact of the prehabilitation protocol. PFM function measures were enhanced following RP in the intervention group. Secondary measures (IPSS, EPIC-CP and RTUS PFM function tests) demonstrated improvement across all time points, with the intervention group displaying consistently lower "bothersome" scores.

CONCLUSIONS

A pelvic floor muscle exercise program commenced prior to prostate surgery enhanced post-surgical measures of pelvic floor muscle function, reduced PPI and improved QoL outcomes related to incontinence.

TRIAL REGISTRATION

The trial was registered in the Australia New Zealand Clinical Trials Registry and allocated as ACTRN12617001400358. The trial was registered on 4/10/2017 and this was a retrospective registration.

Outcome of Enhanced Recovery After Surgery (ERAS) for Colorectal Surgery in Early Elderly and Late Elderly Patients

INTRODUCTION

This study aimed to determine the outcome of enhanced recovery after surgery (ERAS) programme in elderly colorectal surgery patients.

MATERIALS AND METHODS

Details and surgical outcomes of elderly patients undergoing elective colectomy and/or proctectomy according to ERAS protocol from 2011 to 2017 were retrospectively reviewed. Patients were divided into 2 groups: early elderly (EE, n = 107) aged 65-74 years old and late elderly (LE, n = 74) aged ≥75 years old.

RESULTS

This study included 181 patients. The LE group had poorer baseline characteristics, but the operative details in both groups were comparable. Overall complication and severe complication rates were 28% and 3.3%, respectively. The LE group had a higher overall complication rate (38% vs 22%; P = 0.016) but comparable rate of severe complications (2.7% vs 3.7%; P = 1.00). Median postoperative stay was 4 days (interquartile range [IQR], 4-6 days) and it was not significantly different between both groups (5 days for LE vs 4 days for EE; P = 0.176). No difference was seen in time to gastrointestinal recovery and 30-day mortality or readmission between both groups. Overall compliance with ERAS protocol was 76% (IQR, 65-82%) and it did not vary significantly between the LE (71%) and EE (76%) groups (P = 0.301). However, the LE group had lower compliance with fluid management, nutrition therapy and use of multimodal analgesia.

CONCLUSION

ERAS is a safe and effective protocol that can be used in EE and LE colorectal surgery patients.

Prehabilitation and Its Role in Geriatric Surgery

As the world's population ages rapidly, many elderly people are living to a much more advanced age than before. Consequently, medical conditions that require surgical interventions such as solid organ cancers are also getting more common. While young and fit patients may be able to withstand surgical stresses and recover rapidly after operation, older adults may find these challenging. Rehabilitation that is instituted in the postoperative period aims to help patients regain physical fitness and robustness to preoperative levels. However, recent studies have shown that prehabilitation may be more effective in bringing the fitness level of elderly patients to a higher level before they go for surgery. There are many controversies regarding the effectiveness of prehabilitation, the components of this intervention-be it mono- or multimodalities-and the duration of prehabilitation. This paper looks at the current evidence of this hot topic revolving geriatric surgery.

The pre- and postoperative course of functional status in patients undergoing esophageal cancer surgery

INTRODUCTION

To optimally target physiotherapy treatment, knowledge of the pre- and postoperative course of functional status in patients undergoing esophagectomy is required. The aim of this prospective longitudinal study was to investigate the course of functional status in patients with esophageal cancer before and after esophagectomy.

MATERIALS AND METHODS

Functional status outcome measures of patients with esophageal cancer who underwent surgery between March 2012 and June 2016 were prospectively measured at 3 months and at 1 day before surgery and at 1 week and at 3 months after surgery. Analysis of repeated measurements with the mixed model approach was used to study changes over time.

RESULTS

Hundred fifty-five patients were measured at 3 months and at 1 day before surgery, of which 109 (70.3%) at 1 week and 60 (38.7%) at 3 months after surgery. Mean (SD) age at surgery was 63.5 years (9.3), and 122 patients (78.7%) were male. The incidence of postoperative complications was 83 (53.5%). Three months postoperatively, functional status measures returned to baseline levels, except from handgrip strength (beta [95% CI] -6.2 [-11.3 to -1.1]; P = 0.02) and fatigue (4.7 [0.7to 8.7]; P = 0.02). No differences were observed in the course of functional status between patients with and without postoperative complications.

CONCLUSION

Functional status of patients undergoing esophagectomy returned to baseline values three months after surgery, despite the high incidence of postoperative complications. This requires rethinking the concept of prehabilitation, where clearly not all patients benefit from high functional status to prevent postoperative complications.

Medical resource utilization and costs for intraoperative and early postoperative periprosthetic hip fractures following total hip arthroplasty in the medicare population: A retrospective cohort study

This study assessed the impact of intraoperative and early postoperative periprosthetic hip fractures (PPHFx) after primary total hip arthroplasty (THA) on health care resource utilization and costs in the Medicare population.This retrospective observational cohort study used health care claims from the United States Centers for Medicare and Medicaid Standard Analytic File (100%) sample. Patients aged 65+ with primary THA between 2010 and 2016 were identified and divided into 3 groups - patients with intraoperative PPHFx, patients with postoperative PPHFx within 90 days of THA, and patients without PPHFx. A multi-level matching technique, using direct and propensity score matching was used. The proportion of patients admitted at least once to skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), and readmission during the 0 to 90 or 0 to 365 day period after THA as well as the total all-cause payments during those periods were compared between patients in PPHFx groups and patients without PPHFx.After dual matching, a total 4460 patients for intraoperative and 2658 patients for postoperative PPHFx analyses were included. Utilization of any 90-day post-acute services was statistically significantly higher among patients in both PPHFx groups versus those without PPHFx: for intraoperative analysis, SNF (41.7% vs 30.8%), IRF (17.7% vs 10.1%), and readmissions (17.6% vs 11.5%); for postoperative analysis, SNF (64.5% vs 28.7%), IRF (22.6% vs 7.2%), and readmissions (92.8% vs 8.8%) (all P < .0001). The mean 90-day total all-cause payments were significantly higher in both intraoperative ($30,114 vs $21,229) and postoperative ($53,669 vs $ 19,817, P < .0001) PPHFx groups versus those without PPHFx. All trends were similar in the 365-day follow up.Patients with intraoperative and early postoperative PPHFx had statistically significantly higher resource utilization and payments than patients without PPHFx after primary THA. The differences observed during the 90-day follow up were continued over the 1-year period as well.

Impaired neuromuscular control up to postoperative 1 year in operated and nonoperated knees after anterior cruciate ligament reconstruction

The current study was performed to assess serial changes in neuromuscular control until 1 year postoperatively in nonathletic patients undergoing anterior cruciate ligament reconstruction (ACLR).Ninety-six patients were included. Serial neuromuscular control tests were performed preoperatively, at 6 months, and 1 year postoperatively. Neuromuscular control was evaluated using acceleration time (AT) and dynamic postural stability (overall stability index, OSI). Functional activity levels were assessed using the Tegner activity-level scale.Preoperative AT of quadriceps and hamstrings in operated knees was 78.9 ± 6.4 and 86.5 ± 6.2 ms, respectively, which significantly reduced to 56.9 ± 2.0 and 62.5 ± 2.8 ms at 1 year (P = 0.006 and 0.002, respectively). In nonoperated knees, preoperative AT of quadriceps and hamstrings was 47.6 ± 1.7 and 56.5 ± 1.7 ms, respectively, which was significantly prolonged to 54.3 ± 2.0 and 67.9 ± 2.7 ms at 1 year (P = 0.02 and 0.001, respectively). Preoperative OSI of nonoperated knees was 1.2 ± 0.0°. It significantly increased to 1.5 ± 0.1° at 1 year (P < 0.001). In operated knees, preoperative OSI was 1.8 ± 0.1°. It significantly decreased to 1.4 ± 0.1° at 1 year (P = 0.001). Tegner scale at 6 months and 1 year were significantly lower than pre-operative scale (P < 0.001). AT and OSI on both knees showed significant negative correlation with Tegner scale at 6 months and 1 year.Neuromuscular control in both knees was not restored to preoperative levels of the nonoperated knees until 1 year after ACLR. Therefore, clinicians and physical therapists should attempt to enhance neuromuscular control in both nonoperated and operated knees.

Manipulation under anesthesia following total knee arthroplasty: a comprehensive review of literature

INTRODUCTION

The etiology of the stiff knee after total knee arthroplasty (TKA) is largely unknown, although excessive scar tissue due to arthrofibrosis is an important reason for a limited range of motion (ROM) after this procedure. Persistent limited ROM after TKA results in poor patient-reported outcomes and is increasingly becoming a more prominent reason for TKA revision surgery.

METHODS

A narrative review of current literature on manipulation under anesthesia (MUA) after TKA analyzing etiology and risk factors for stiffness after TKA, effectiveness of MUA and what is known about rehabilitation after MUA.

RESULTS

Literature describes numerous risk factors for insufficient knee ROM after TKA, but a comprehensive valid risk model is lacking. MUA is an effective treatment option with evidence suggesting better outcomes if performed within the first 3 months after TKA. The wide variety in both the indication and timing for MUA, and the lack of scientific evidence on how to rehabilitate patients after MUA, complicates the interpretation of available literature. This is even more so the case on the reporting of one versus two or more MUAs after TKA.

CONCLUSION

Future comparative trials, preferably with a randomized study design, should be conducted to elude more clear indications for MUA, to give clinical guidance on correct timing for MUA and on how to rehabilitate patients afterward.

[Application and effect of enhanced recovery after surgery in early rehabilitation of oral cancer patients after operation]

PURPOSE

To explore the application and effect of enhanced recovery after surgery (ERAS) in early rehabilitation of oral cancer patients after operation.

METHODS

Ninety cases of oral cancer admitted from January 2016 to December 2017 were randomly divided into two groups. 45 cases of oral cancer in the experimental group received ERAS nursing after operation, and another 45 patients received routine nursing after operation. The sleep duration, pain and halitosis 3 days after operation; the first time to get out of bed, the length of hospitalization; and the level of albumin and other laboratory indicators 1 and 3 days after operation were observed. SPSS 17.0 software package was used for statistical analysis.

RESULTS

After 1 day and 3 day of ERAS intervention, the nutritional index of the experimental group was lower than that of the control group. The time of first ambulation and the length of hospitalization were shorter than those of the control group. The average sleep time 3 days after operation was longer than that of the control group. The incidence of halitosis, wound infection and moderate pain was lower than that of the control group. The difference was statistically significant (P<0.05).

CONCLUSIONS

ERAS nursing after oral cancer surgery can improve the comfort of patients, enhance the clinical outcome, promote rapid recovery of patients, with good clinical application prospects.

Penile rehabilitation for postprostatectomy erectile dysfunction

BACKGROUND

Despite efforts to preserve the neurovascular bundles with nerve-sparing surgery, erectile dysfunction remains common following radical prostatectomy. Postoperative penile rehabilitation seeks to restore erectile function but results have been conflicting.

OBJECTIVES

To evaluate the effects of penile rehabilitation strategies in restoring erectile function following radical prostatectomy for prostate cancer.

SEARCH METHODS

We performed a comprehensive search of multiple databases (CENTRAL, MEDLINE, Embase), the Cochrane Library, Web of Science, clinical trial registries (ClinicalTrials.gov, International Clinical Trials Registry Platform) and a grey literature repository (Grey Literature Report) from their inception through to 3 January 2018. We also searched the reference lists of other relevant publications and abstract proceedings. We applied no language restrictions.

SELECTION CRITERIA

We included randomised or quasi-randomised trials with a parallel or cross-over design.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Two review authors independently screened the literature, extracted data, assessed risk of bias and rated quality of evidence according to GRADE on a per-outcome basis. Primary outcomes were self-reported potency, erectile function measured by validated questionnaires (with potency defined as an International Index of Erectile Function (IIEF-EF) score of 19 or greater and or an IIEF-5 of score of 17 or greater) and serious adverse events. For all quality of life assessments on a continuous scale, higher values indicated better quality of life.

MAIN RESULTS

We included eight randomised controlled trials with 1699 participants across three comparisons. This abstract focuses on the primary outcomes of this review only.Scheduled phosphodiesterase type 5 inhibitors (PDE5I) versus placebo or no treatmentScheduled PDE5I may have little or no effect on short-term (up to 12 months) self-reported potency (risk ratio (RR) 1.13, 95% confidence interval (CI) 0.91 to1.41; very low quality evidence), which corresponds to 47 more men with self-reported potency per 1000 (95% CI 33 fewer to 149 more) and short-term erectile function as assessed by a validated instrument (RR 1.11, 95% CI 0.80 to 1.55; very low quality evidence), which corresponds to 28 more men per 1000 (95% CI 50 fewer to 138 more), but we are very uncertain of both of these findings. Scheduled PDE5I may result in fewer serious adverse events compared to placebo (RR 0.32, 95% CI 0.11 to 0.94; low quality evidence), though this does not appear biologically plausible and may represent a chance finding. We are also very uncertain of this finding. We found no long-term (longer than 12 months) data for any of the three primary outcomes.Scheduled PDE5I versus on-demand PDE5I Daily PDE5I appears to result in little to no difference in both short-term and long-term (greater than 12 months) self-reported potency (short term: RR 0.97, 95% CI 0.62 to 1.53; long term: RR 1.00, 95% CI 0.60 to 1.67; both very low quality evidence); this corresponds to nine fewer men with self-reported short-term potency per 1000 (95% CI 119 fewer to 166 more) and zero fewer men with self-reported long-term potency per 1000 (95% CI 153 fewer to 257 more). We are very uncertain of these findings. Daily PDE5I appears to result in little to no difference in short-term and long-term erectile function (short term: RR 1.00, 95% CI 0.65 to 1.55; long term; RR 0.74, 95% CI 0.48 to 1.14; both very-low quality evidence), which corresponds to zero men with short-term erectile dysfunction per 1000 (95% CI 80 fewer to 125 more) and 119 fewer men with long-term erectile dysfunction per 1000 (95% CI 239 fewer to 64 more). We are very uncertain of these findings. Scheduled PDE5I may result in little or no effects on short-term adverse events (RR 0.69 95% CI 0.12 to 4.04; very low quality evidence), which corresponds to seven fewer men with short-term serious adverse events (95% CI 18 fewer to 64 more), but we are very uncertain of these findings. We found no long-term data for serious adverse events.Scheduled PDE5I versus scheduled intraurethral prostaglandin E1At short-term follow-up, daily PDE5I may result in little or no effect on self-reported potency (RR 1.10, 95% CI 0.79, to 1.52; very low quality evidence), which corresponds to 46 more men per 1000 (95% CI 97 fewer to 241 more). Daily PDE5I may result in a small improvement of erectile function (RR 1.64, 95% CI 0.84 to 3.20; very low quality evidence), which corresponds to 92 more men per 1000 (95% CI 23 fewer to 318 more) but we are very uncertain of both these findings. We found no long-term (longer than 12 months) data for any of the three primary outcomes.We found no evidence for any other comparisons and were unable to perform any of the preplanned subgroup analyses based on nerve-sparing approach, age or baseline erectile function.

AUTHORS' CONCLUSIONS

Based on mostly very-low and some low-quality evidence, penile rehabilitation strategies consisting of scheduled PDE5I use following radical prostatectomy may not promote self-reported potency and erectile function any more than on demand use.

Thoracic outlet syndrome (TOS): A case report of a rare complication after Nuss procedure for pectus excavatum

RATIONALE

The Nuss procedure has become a major alternative operation for patients with pectus excavatum (PE).

PATIENT CONCERNS

We report a case of 27-year-old man with PE who developed thoracic outlet syndrome (TOS) after the Nuss procedure. The patient showed clinical symptoms of brachial plexus compression.

DIAGNOSES

Further evaluation demonstrated a narrowed space between the first rib and the anterior scalene muscle and compressing the brachial plexus and vessels.

INTERVENTIONS

Nerve nourishing medicine and rehabilitation exercising were taken to restore the muscle strength.

OUTCOMES

Several months later, the clinical symptoms disappeared.

LESSONS

Medicine and rehabilitation exercising may benefit the functional recovery of impaired nerve in TOS in the early stage of TOS.

[CERVICAL CANCER REHABILITATION: A PROSPECTIVE STUDY]

Aim - to evaluate the rehabilitation program impact on the quality of life of оncogynecological patients and to introduce this approach in clinical practice. The study included93 reproductive-aged women, who underwent the cervical cancer treatment. Patients were divided into two groups: the experimental group, which received rehabilitation, and the control group. The thrombotic complications risk, lymphatic system condition, cognitive functions and anxiety level were assessed in all patients using special questionnaires, physical examination, and laboratory assessment. The lower limbs lymphedema was observed in 19.1% of cases in the control group and in 2.1% in the experimental group (p <0.05). According to the Moka test data, cognitive impairment level at the end of the study was 24.02 (17-30, CI: = 22.5-25.54) in the control group and 26.85 (19-30, CI: = 26.0 - 27.64) in the experimental group (p <0.05). The cognitive impairment subjective signs were significantly higher in the control group (p <0.05) as well. The anxiety level at the end of the study was 7.022 (1-19, CI: = 5.91-8.13) in the experimental group and 11.02 (4-22, CI: = 9.83-12.22) in the control group (p <0.05). At the end of the study, the following depression levels were obtained: 12.43 (5 - 21; CI: = 11.23 - 13.64) and 7.69 (1 -14; CI: = 6.77 - 8.62) in the control and the experimental group respectively (p <0.05). At the end of the study, deep vein thrombosis was observed in 21 patients in the control group (44.7%) and 7 patients in the experimental group (15.22%) (p <0.05). One patient from the control group had PATE. According to EORTC QLQ-C30, the quality of life and socialization level was significantly higher in the experimental group, while fatigue level was lower. At the end of the study, 36.2% and 76.0% of patients in the control and the experimental group respectively were employed. The rehabilitation program improves the emotional and cognitive functioning, induced menopause associated somatic disorders, quality of life, and work capacity.

Physiotherapy and Anterior Resection Syndrome (PARiS) trial: feasibility study protocol

INTRODUCTION

Rectal cancer affects more than 600 patients per year in Wales, with a 5-year survival rate of around 60%. A recent report demonstrated that 19% of patients with bowel cancer had difficulty controlling their bowels after surgery, and these patients were twice as likely to report lower quality of life than those who had control. Nearly all patients will experience bowel dysfunction initially following surgery and up to 25% will experience severe bowel dysfunction on a long-term basis. The aim of this study is to test the feasibility of introducing a simple intervention in an attempt to improve bowel function following surgery for rectal cancer. We propose the introduction of an educational session from specialist nurses and physiotherapists prior to surgery and a subsequent physiotherapy programme for 3 months to teach patients how to strengthen their pelvic floor.

METHODS AND ANALYSIS

All patients with rectal cancer planned to receive an anterior resection will be approached for the study. The study will take place in three centres over 12 months, and we expect to recruit 40 patients. The primary outcome measure is the proportion of eligible patients approached who consent to and attend the educational session. The secondary outcomes include patient compliance to the pelvic floor rehabilitation programme (assessed by patient paper or electronic diary), the acceptability of the intervention to the patient (assessed using qualitative interviews) and preoperative and postoperative pelvic floor tone (assessed using the Oxford Grading System and the International Continence Society Grading System), patient bowel function and patient quality of life (assessed using validated questionnaires).

ETHICS AND DISSEMINATION

Ethics approval was granted. This feasibility study is in progress. If patients find the intervention acceptable, the next stage would be a trial comparing outcomes after anterior resection in those who have and do not have physiotherapy.

TRIAL REGISTRATION NUMBER

ISRCTN77383505; Pre-results.

Physical performance following acute high-risk abdominal surgery: a prospective cohort study

BACKGROUND

Acute high-risk abdominal (AHA) surgery is associated with high mortality, multiple postoperative complications and prolonged hospital stay. Further development of strategies for enhanced recovery programs following AHA surgery is needed. The aim of this study was to describe physical performance and barriers to independent mobilization among patients who received AHA surgery (postoperative days [POD] 1-7).

METHODS

Patients undergoing AHA surgery were consecutively enrolled from a university hospital in Denmark. In the first postoperative week, all patients were evaluated daily with regards to physical performance, using the Cumulated Ambulation Score (CAS; 0-6 points) to assess basic mobility and the activPAL monitor to assess the 24-hour physical activity level. We recorded barriers to independent mobilization.

RESULTS

Fifty patients undergoing AHA surgery (mean age 61.4 ± 17.2 years) were included. Seven patients died within the first postoperative week, and 15 of 43 (35%) patients were still not independently mobilized (CAS < 6) on POD-7, which was associated with pulmonary complications developing (53% v. 14% in those with CAS = 6, p = 0.012). The patients lay or sat for a median of 23.4 hours daily during the first week after AHA surgery, and the main barriers to independent mobilization were fatigue and abdominal pain.

CONCLUSION

Patients who receive AHA surgery have very limited physical performance in the first postoperative week. Barriers to independent mobilization are primarily fatigue and abdominal pain. Further studies investigating strategies for early mobilization and barriers to mobilization in the immediate postoperative period after AHA surgery are needed.

Enhanced recovery after surgery (ERAS) programs for esophagectomy protocol for a systematic review and meta-analysis

BACKGROUND

Esophageal cancer is one of the worst malignant digestive neoplasms with poor treatment outcomes. Esophagectomy plays an important role and offers a potential curable chance to these patients. However, esophagectomy with radical lymphadenectomy is known as one of the most invasive digestive surgeries which are associated with high morbidity and mortality. The enhanced recovery after surgery (ERAS) protocol is a patient-centered, surgeon-led system combining anesthesia, nursing, nutrition, and psychology, which is designed for reducing complications, promoting recovery, and improving treatment outcomes. This systematic review and meta-analysis is aiming at how beneficial, and to what extent ERAS really will be.

METHODS

A systematic literature search will be performed through January 2018 using MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and Google Scholar for relevant articles published in any language. Randomized controlled trials, prospective cohort studies, and propensity-matched comparative studies will be included. All meta-analyses will be performed using Review Manager software. The quality of the studies will be evaluated using the guidelines listed in the Cochrane Handbook. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statements will be followed until the findings of the systematic review and meta-analysis are reported.

RESULTS

The results of this systematic review and meta-analysis will be published in a peer-reviewed journal.

CONCLUSION

Our study will draw an objective conclusion of the comparisons between ERAS and conventional care in aspects of perioperative outcomes and provide level I evidences for clinical decision makings.

[Fast track rehabilitation in perforated duodenal ulcer]

AIM

To analyze the outcomes of fast track rehabilitation program in patients with perforated duodenal ulcer (PDU).

MATERIAL AND METHODS

For the period 2013-2016 at the Department of Surgery and Endoscopy 206 PDU patients have been treated. Inclusion criterion for the main group (n=77) was duodenal ulcers, their dimension up to 1 cm, laparoscopic suture of perforated ulcer, fast track rehabilitation program implementation. The control group consisted of 129 patients who underwent open suturing of perforated ulcer followed by conventional treatment in postoperative period.

RESULTS

In the main group (n=77) laparoscopic suturing of ulcerative defect with the use of Fast Track program was performed. Postoperative complication i.e. sutures failure was observed in 1 (1.3%) case. There were no lethal outcomes in the main group. Mean length of hospital-stay was 4.8 days. In 129 patients of the control group open suturing of the perforated ulcer and conventional postoperative therapy were applied. Postoperative surgical complications were absent in the control group; mortality rate was 2.3%. Mean length of postoperative hospital-stay was 8.1 days.

CONCLUSION

Laparoscopic treatment of perforated ulcers facilitates application of fast track rehabilitation program in emergency patients. Fast track rehabilitation protocol after laparoscopic suturing of the perforated ulcer creates conditions for early discharge and is followed by good clinical and economic effects. Recurrent peptic ulcers are noted if antiulcer therapy is absent.

Effect of low appendicular lean mass, grip strength, and gait speed on the functional outcome after surgery for distal radius fractures

Patients with low appendicular lean mass plus slow gait speed or weak grip strength are at risk for poor functional recovery after surgery for distal radius fracture, even when they have similar radiologic outcomes.

INTRODUCTION

Loss of skeletal muscle mass and consequent loss in muscle function associate with aging, and this condition negatively impacts the activities of daily living and increases elderly individuals' frailty to falls. Thus, patients with low appendicular lean mass would show different functional recovery compared to those without this condition after surgery for distal radius fracture (DRF). This study compares the functional outcomes after surgery for DRF in patients with or without low appendicular lean mass plus slowness or weakness.

METHODS

A total of 157 patients older than 50 years of age with a DRF treated via volar plate fixation were enrolled in this prospective study. A definition of low appendicular lean mass with slowness or weakness was based on the consensus of the Asian Working Group for Sarcopenia. The researchers compared functional assessments (wrist range of motion and Michigan Hand Questionnaire [MHQ]) and radiographic assessments (radial inclination, volar tilt, ulnar variance, and articular congruity) 12 months after surgery between patients with and without low appendicular lean mass plus slowness or weakness. Multivariable regression analyses were performed to determine whether appendicular lean mass, grip strength, gait speed, patient demographic, or injury characteristics accounted for the functional outcomes.

RESULTS

Patients with low appendicular lean mass plus slowness or weakness showed a significantly lower recovery of MHQ score than those in the control group throughout 12 months. There was no significant difference in the range of motion between the groups. The radiologic outcomes showed no significant difference between groups in terms of volar tilt, radial inclination, or ulnar variance. According to multivariable regression analysis, the poor recovery of MHQ score was associated with an increase in age, weak grip strength, and lower appendicular lean mass, and these three factors accounted for 37% of the variation in the MHQ scores.

CONCLUSION

Patients with low appendicular lean mass plus slowness or weakness are at risk for poor functional recovery after surgery for DRF, even when they have similar radiologic outcomes.

Protocol for a single-centre, randomised controlled study of a preoperative rehabilitation bundle in the frail and elderly undergoing abdominal surgery

INTRODUCTION

Frail patients have decreased physiological reserves and consequently, they are unable to recover as quickly from surgery. Frailty, as an entity, is a risk factor of increased morbidity and mortality. It is also associated with a longer time to discharge. This trial is undertaken to determine if a novel prehabilitation protocol (10-day bundle of interventions-physiotherapy, nutritional supplementation and cognitive training) can reduce the postoperative length of stay of frail patients who are undergoing elective abdominal surgery, compared with standard care.

METHODS AND ANALYSIS

This is a prospective, single-centre, randomised controlled trial with two parallel arms. 62 patients who are frail and undergoing elective abdominal surgery will be recruited and randomised to receive either a novel prehabilitation protocol or standard care. Participants will receive telephone reminders preoperatively to encourage protocol compliance. Data will be collected for up to 30 days postoperatively. The primary outcome of the trial will be the postoperative length of stay and the secondary outcomes are the postoperative complications and functional recovery during the hospital admission.

ETHICS AND DISSEMINATION

This study has been approved by the Singapore General Hospital Institutional Review Board (CIRB Ref: 2016/2584). The study is also listed on ClinicalTrials.gov (Trial number: NCT02921932). All participants will sign an informed consent form before randomisation and translators will be made available to non-English speaking patients. The results of this study will be published in peer-reviewed journals as well as national and international conferences. The data collected will also be made available in a public data repository.

TRIAL REGISTRATION NUMBER

NCT02921932 (ClinicalTrials.gov).

Comprehensive comparing percutaneous endoscopic lumbar discectomy with posterior lumbar internal fixation for treatment of adjacent segment lumbar disc prolapse with stable retrolisthesis: A retrospective case-control study

The study was to comprehensively compare the postoperative outcome and imaging parameter characters in a short/middle period between the percutaneous endoscopic lumbar discectomy (PELD) and the internal fixation of bone graft fusion (the most common form is posterior lumbar interbody fusion [PLIF]) for the treatment of adjacent segment lumbar disc prolapse with stable retrolisthesis after a previous lumbar internal fixation surgery.In this retrospective case-control study, we collected the medical records from 11 patients who received PELD operation (defined as PELD group) for and from 13 patients who received the internal fixation of bone graft fusion of lumbar posterior vertebral lamina decompression (defined as control group) for the treatment of the lumbar disc prolapse combined with stable retrolisthesis at Department of Spine Surgery, the Third Hospital of Hebei Medical University (Shijiazhuang, China) from May 2010 to December 2015. The operation time, the bleeding volume of perioperation, and the rehabilitation days of postoperation were compared between 2 groups. Before and after surgery at different time points, ODI, VAS index, and imaging parameters (including Taillard index, inter-vertebral height, sagittal dislocation, and forward bending angle of lumbar vertebrae) were compared.The average operation time, the blooding volume, and the rehabilitation days of postoperation were significantly less in PELD than in control group. The ODI and VAS index in PELD group showed a significantly immediate improving on the same day after the surgery. However, Taillard index, intervertebral height, sagittal dislocation in control group showed an immediate improving after surgery, but no changes in PELD group till 12-month after surgery. The forward bending angle of lumbar vertebrae was significantly increased and decreased in PELD and in control group, respectively.PELD operation was superior in terms of operation time, bleeding volume, recovery period, and financial support, if compared with lumbar internal fixation operation. Radiographic parameters reflect lumber structure changes, which could be observed immediately after surgery in both methods; however, the recoveries on nerve function and pain relief required a longer time, especially after PLIF operation.

Patient Perception of Speech Outcomes: The Relationship Between Clinical Measures and Self-Perception of Speech Function Following Surgical Treatment for Oral Cancer

PURPOSE

Treatment for oral cancer can result in speech impairments that can have varying impacts on patient quality of life. This study explored the relationship between clinical measures of speech impairment and the perception that patients had of this change in the early stage of recovery.

METHOD

This was a quasi-experimental 1-group pre-post study design carried out on 10 patients with surgical intervention for oral cancer. Two clinical measures (word intelligibility and consonant phoneme error) and 2 patient-perception measures (Speech Handicap Index total score and Speech Handicap Index patient criteria score) were collected at preoperative and 1-month postoperative appointments.

RESULTS

Qualitative analysis revealed discordance between clinical and patient-perceived measures in 4 of 10 patients. Change in consonant phoneme error and change in word intelligibility were significantly correlated (r = .827). Furthermore, on average, statistically significant relationships were not found between clinical and patient-perceived measures or between the 2 patient-perception measures.

CONCLUSIONS

Discordance between clinical and patient-perceived measures was observed in almost half of the sample, indicating that clinical tests did not fully explain the extent of impairment perceived by patients. Speech outcomes should focus on both types of measures, and patient perception outcomes should be carefully considered when recommending speech therapy.

Impact of an enhanced recovery after surgery programme in radical cystectomy. A cohort-comparative study

OBJECTIVE

To evaluate the results of the implementation of an enhanced recovery program (ERAS) for open approach radical cystectomy compared to the historical cohort of the same hospital.

MATERIAL AND METHODS

A retrospective analysis of 138 consecutive patients who underwent radical cystectomy with Bricker or Studer ileal derivation (97 historical vs. 41 ERAS). Overall complication rate, Clavien-Dindo stage>2 complications, mortality, hospital and critical care length of stay and readmission rates, as well as need for reoperation, nasogastric intubation, transfusion or parenteral nutrition were compared.

RESULTS

No statistically significant differences in overall complication rate were found (73.171 vs. 77.32%; OR 1.25, 95% CI 0.54-2.981; P=.601) nor in Clavien-Dindo>2 complications (41.463 vs. 42.268%; OR 1.033, 95% CI 0.492-2.167; P=.93), mortality, lengths of stays readmission and reoperation rates. The need for nasogastric tube insertion was lower in the ERAS group (43.902 vs. 78.351%; OR 4.624, 95% CI 2.112-10.123; P<.0001), as well as the need for total parenteral nutrition (26.829 vs. 34.021%; OR 12.234, 95% CI 5.165-28.92; P<.0001), and time under endotracheal intubation since anaesthesia induction (median [IRQ]=325 (285-355) vs. 540 (360-600) min; P<.0001).

CONCLUSION

Enhanced recovery programs in radical cystectomy decrease interventionism on the patient without increasing morbidity and mortality.

[A case of central pontine and extrapontine myelinolysis after surgery for a pituitary tumor]

A 21-year-old woman underwent surgery for a pituitary tumor. On the 11th postoperative day, blood examination revealed severe hyponatremia, with a serum sodium level of 111 mEq/l, and two days later this increased rapidly to 137 mEq/l. On the 20th postoperative day, the patient developed dysarthria and gait disturbance. Head MRI on the 30th postoperative day demonstrated intense high-signal lesions in the pons and bilateral corpus striatum on FLAIR and DWI, and central pontine and extrapontine myelinolysis was diagnosed. The patient's symptoms improved gradually after rehabilitation and antispasticity treatment. It was suggested that the changes in serum sodium levels after pituitary surgery were due to impaired secretion of antidiuretic hormone due to degeneration of nerve terminals in the posterior pituitary. As pituitary surgery may trigger changes in serum sodium leading to myelinolysis, this possibility should always be borne in mind when treating such patients.

Lessons Learned from the Management of Complex Intra-Articular Fractures at the Base of the Middle Phalanges of Fingers

The use of dynamic traction splintage is established in the treatment of complex intra-articular phalangeal fractures. Several different systems have been used and we report our experience with one of these, the Pins and Rubber Traction System. A cohort of 14 patients with complex intra-articular fractures at the base of the middle phalanges of the fingers were treated and assessed prospectively over a 2.5-year period (mean, 20 months; range, 7–28 months). The mean active range of motion regained, at the proximal interphalangeal joint, was 74° (range, 0–100°). The mean total active motion of the injured digit was 196° (range, 40–275°). Refinements in the regime are suggested as a result of this investigation.

Results of Ray Resection and Amputation for Ring Avulsion Injuries at the Proximal Interphalangeal Joint

We investigated the long-term functional results of ray resection (14 cases) and amputation (nine cases) for ring avulsion injuries of ring finger which could not be replanted or underwent failed replantation. The mean follow-up was 37 (range, 24–63) months in the ray resection group and 32 (range, 24–40) months in the amputation group. Grip strength, key pinch strength, chuck pinch strength, hand circumference and palmar volume were decreased in the ray resection group but only grip strength and pulp pinch strength were significantly decreased in the amputation group. These results suggest that ray resection should be avoided in patients with occupations that need strong key and chuck pinch functions.

Immediate versus delayed aggressive physical therapy following buccal fat pad interposition in oral submucous fibrosis-a prospective study in Central India

PURPOSE

Oral submucous fibrosis is a disease of an Indian subcontinent with obscure aetiology and poorly treated with varying signs and symptoms. OSMF occurs at any age but is most commonly seen in teenagers and adults in the age ranging between 16 and 35 years. A number of surgical treatments have been used for the treatment of oral submucous fibrosis with unpredictable results.

PATIENTS AND METHOD

In this study, 220 patients were randomly divided into two groups with mouth opening less than 16 mm and evaluated with immediate and delayed aggressive physiotherapy with buccal fat pad interposition after fibrotomy. Group A (n = 110) patients underwent aggressive mouth opening exercise from the next postoperative day while in group B (n = 110), patients underwent physiotherapy 7th day postoperatively. Pain and discomfort, mucosalization, infection, flap dehiscence and necrosis were noted. Patients were followed for 1 year on a regular interval basis.

RESULTS

At the end of 1-year follow up, the post-operative mean mouth opening in group A was 38.63 mm and 34.19 mm in group B. In group A, the immediate physiotherapy results in mild to moderate pain and discomfort to the patients as compared to no apparent pain in the group B. The mean mucosalization time in group A and group B was 4.2 and 5.1 weeks, respectively. Postoperatively, all patients achieve satisfactory mouth opening.

CONCLUSION

Immediate aggressive physiotherapy yields a comparatively superior result than delayed physiotherapy with respect to mouth opening in 1 year of follow-up.

Quadruple zygomatic implants supported rehabilitation in failed maxillary bone reconstruction

Extreme atrophy of the jaws constitutes a challenge for maxillofacial surgeons. The technique involving Le Fort I osteotomy, bone grafting, and endosseous implants remains the gold standard treatment for class V and class VI atrophy of the maxilla. As severe maxillary atrophy is associated to impaired microvascularization of overlying soft tissues, reconstruction using vascularized free fibula flaps together with endosseous implants is one of the possible treatment plans. When this approach fails, however, retreating these patients using traditional techniques often proves unsatisfactory. This study outlines our clinical experience with full-arch zygoma implant-supported prosthetic rehabilitation to treat severe atrophic maxilla following failure of strategies including multiple Le Fort I procedures or vascularized free fibular flaps.

Exercise and cancer: return to work as a firefighter with ostomy after rectal carcinoma - a case report

BACKGROUND

Colorectal cancer survivors are deconditioned through anticancer therapy. Furthermore, about 10% of them have a permanent ostomy which is associated with weakened abdominal muscles and an increased risk of a hernia. This case study reports on how a firefighter with rectal carcinoma and ostomy was trained to regain operational fitness.

METHODS

A 44-year-old firefighter (178 cm, 82 kg) with an adenocarcinoma of the rectum (diagnosed 24 months prior) had been treated with neoadjuvant radiochemotherapy and surgery. After 2 temporary ileostomies, a permanent colostomy was performed 14 weeks before the start of a 9-months training program. The program included sensorimotor, endurance, and strength training of increasing volume and intensity. Endurance, strength, and patient reported outcomes were assessed every 2 to 3 months.

RESULTS

Training frequency varied from 1 to 3 sessions/week, although 3 to 5 sessions/week were prescribed. Peak power output was 150, 158, 167, 192, and 175 watts at baseline, 2, 4, 6, and 9 months. Maximal oxygen uptake increased from 1.56 L/min (19.0 mL/min/kg) to 2.39 L/min (28.8 mL/min/kg) after 6 months. Maximal isokinetic peak torque (MIPT) of the knee extensors were 138.0 and 196.5 Nm (Newton meter) at baseline and 6 months. MIPT of the elbow and hip flexors increased from 51.8 to 66.0 Nm and 213.8 to 239.7 Nm, respectively, after 6 months. Physical fatigue decreased by 65% and distress by about 50% after 9 months. The firefighter passed a test for occupational fitness after 6 months and was permitted to work with an exterior crew on a pump truck.

CONCLUSION

It is possible for colorectal cancer survivors with ostomy to regain occupational fitness for physically demanding tasks like firefighting through an individually tailored and supervised training program.

Efficacy of buccal fat pad in the surgical management of oral submucous fibrosis: a prospective study

PURPOSE

Various surgical treatment modalities have been advocated in the surgical management of oral submucous fibrosis with variable results. This prospective study evaluates the efficacy of buccal fat pad in the surgical treatment of oral submucous fibrosis.

PATIENTS AND METHOD

In the present study, 20 patients were treated for oral submucous fibrosis with interincisal mouth opening less than 16 mm. Surgical procedure included fibrotomy, all third molar extractions, and coronoidotomy or coronoidectomy followed by reconstruction of fibrotomy defect with buccal pad of fat. Postoperatively, patients were prescribed nutritional and antioxidant supplements along with vigorous mouth opening exercise for 6 months. Regular follow-up was carried out for 2 years.

RESULTS

Excellent increase in the interincisal mouth opening was noticed relieving trismus. Patient's ability of masticate and tolerance to regular food was increased significantly. Buccal fat pad underwent rapid epithelization within a period of 5-7 weeks.

CONCLUSION

Buccal fat pad can be used effectively in the surgical management of oral submucous fibrosis with good functional and esthetic outcome, with only drawback of supple lobulated fat, which requires delicate handling and its limitation to reach anteriorly beyond the canine region.

Effect of Teres Minor Fatty Infiltration on Rotator Cuff Repair Outcomes

PURPOSE

To observe changes in fatty infiltration (FI) of the teres minor without tear of the teres minor in a postoperative magnetic resonance imaging and to evaluate the influence of FI of the teres minor in the clinical outcomes of rotator cuff repair.

METHODS

Of 816 patients who underwent rotator cuff repair, 51 (6.3%) had FI of the teres minor without tear involvement and 30 cases were available for postoperative magnetic resonance imaging. FI and functional outcome scores were assessed and compared with the control group that had no FI of the teres minor selected by a propensity score matching.

RESULTS

FI of the teres minor was observed in various degrees (grade 1 in 9, grade 2 in 9, grade 3 in 6, and grade 4 in 6). The degree of FI was not related to the amount of tendon involvement of a rotator cuff tear (P = .240). All postoperative functional outcome scores (12.6 ± 1.2 months; range, 11-17), including pain visual analog scale, Simple Shoulder Test, and American Shoulder and Elbow Surgeons Score, significantly improved (all P < .001), and there were no significant differences compared with that of the control group. In most of the cases, FI of the teres minor was unchanged (P = .317).

CONCLUSIONS

FI of the teres minor without tear involvement can be observed in a rotator cuff tear as a possibly incidental finding of unknown clinical significance. Its cause has not been determined, and it appears that FI of the teres minor does not appear to improve, at least at the 1-year follow-up. Nevertheless, the functional outcomes of the repair were successful in our study; therefore, rotator cuff repair can be performed without a great deal of concern in the presence of FI in the teres minor.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

What Is the Efficacy of Repeat Manipulations Under Anesthesia to Treat Stiffness Following Primary Total Knee Arthroplasty?

BACKGROUND

Manipulation under anesthesia (MUA) can help post-total knee arthroplasty (TKA) patients who have knee stiffness regain range-of-motion. However, despite undergoing MUA, patients may have persistent knee stiffness. Often, this persistent knee stiffness is treated with a repeat MUA. Therefore, the purpose of this study was to evaluate repeat MUAs by assessing: (1) demographic characteristics, (2) range-of-motion, (3) clinical outcomes, and (4) rate of revision surgery in post-TKA patients with persistent knee stiffness who either underwent a single MUA or repeat MUAs.

MATERIALS AND METHODS

One-hundred-and-sixty-seven post-TKA who had undergone an MUA between 2005 and 2011 at two institutions were reviewed. Patients were stratified into those who had a single-MUA (138 knees) and those who had a repeat MUA (29 knees). The mean follow-up period was 63 months (range, 36 to 90 months). The incidence of repeat MUA within this cohort was determined. Demographics and ROM were compared using Student t-test and Chi-square as appropriate. Functional outcomes were assessed using Knee Society scores (KSS) and compared between the two cohorts.

RESULTS

Among the 167 patients who underwent a MUA, 29 (17%) required repeat manipulations. The repeat MUA cohort was younger and more likely to have osteonecrosis as the underlying cause of knee disease. For the repeat MUA cohort, 17 patients (59%) had achieved satisfactory mean gains in ROM after their repeat MUAs. These patients had also achieved excellent mean Knee Society objective and functional scores. However, another seven knees (24%) had further persistent knee stiffness requiring arthrolysis of adhesions and five patients (17%) had undergone revision of the polyethylene spacer or patellar component to improve range-of-motion.

CONCLUSION

In this study, the majority of patients who had undergone a repeat MUA were able to achieve improvements in flexion range-of-motion and functional outcomes. However, the remaining patients required more invasive procedure to treat persistent knee stiffness. In patients who have persistent knee stiffness after MUAs, a repeat MUA may be helpful to increase range-of-motion and function.

FEATURES OF REHABILITATION OF THE PATIENTS AFTER NONINFECTIOUS COMPLICATIONS OF TOTAL HIP ARTHROPLASTY

The authors analyzed noninfectious complications (dislocation of endoprosthesis head, periprosthesis fractures) in 8 patients out of 40 with hip arthroplasty. There were estimated clinical, biomechanical results and quality of life of the patients. An application of the external fixator-orthezes should be recommended in order to prevent complications of hip replacement. The wearing of brace is considered to be reasonable after revision interventions.

Safety and functional outcomes associated with short-term rehabilitation therapy in the post-operative management of tibial plateau leveling osteotomy

This retrospective cohort study using electronic questionnaires compared the perioperative complication rates of tibial plateau levelling osteotomy (TPLO) surgery and the 8-week, 6-month, and 1-year functional outcomes, between rehabilitation and traditional post-operative management. Dogs were placed into 1 of 2 cohort groups based on attending veterinarian's selected management: i) "traditional" involving restriction to cage rest and leash walking, and ii) "rehabilitation" performed by a certified practitioner. There was no statistically significant difference in complication rates in the perioperative period between the 2 treatment cohorts (P > 0.1). The rehabilitation group was 1.9 times more likely to reach full function at 8 wk (P = 0.045). Conversely, the traditional group was 2.9 times more likely be categorized as having unacceptable function at 8 wk after surgery (P = 0.05). This study suggests that rehabilitation performed by a certified practitioner is safe and may improve short-term outcomes when used in the initial postoperative management for dogs treated with TPLO.

Gene polymorphism of IL-6 and MMP-3 decreases passive range of motion after rotator cuff repair

OBJECTIVES

Post-operative stiffness is common after rotator cuff repair, given the difference in susceptibility and severity, the genetic factors may be involved. Interleukin 6 (IL-6) and Matrix metalloproteinases 3 (MMP-3) were previous found as key cytokines in the pathologies of adhesive capsulitis. The present study aims to investigate whether variants within the IL-6 and MMP-3 gene contributed to post-operative stiffness in a Chinese Han population.

METHODS

A total of 188 patients diagnosed with rotator cuff tears treated with mini-open surgery were enrolled in this study, among which 87 patients were diagnosed as post-operative stiffness and the remaining 101 patients as controls. All subjects were genotyped for IL-6 and MMP-3 SNPs.

RESULTS

The rs1800796 of IL-6 and rs679620 of MMP-3 were found significantly associated with increased susceptibility and severity of post-operative stiffness.

CONCLUSION

The rs1800796 SNP of IL-6 and rs650108 SNP of MMP-3 were associated with increased risk of post-operative stiffness susceptibility and severity. This finding can be used in guiding the rehabilitation procedure after rotator cuff surgery, in another word, those with the genetic susceptibility factors should receive a more radical rehabilitation procedure and those without the susceptibility factors can be more conservative.

[Penile rehabilitation after radical pelvic surgery]

Prostate cancer, bladder cancer, and rectal cancer are common malignancies in the male pelvis. The incidence rate of erectile dysfunction (ED) following radical prostatectomy, cystectomy or rectal cancer surgery is about 25% - 100%. The main cause of post-surgery ED is mainly attributed to injury of neurovascular bundles, which may lead to reduced oxygenation in and fibrosis of the penile tissue. Early penile rehabilitation after surgery can improve or restore the erectile function of the patients. This article focuses on penile rehabilitation after radical pelvic surgery.

Penile rehabilitation after pelvic cancer surgery

Erectile dysfunction is the most common complication after pelvic radical surgery. Rehabilitation programs are increasingly being used in clinical practice but there is no high level of evidence supporting its efficacy. The principle of early penile rehabilitation stems from animal studies showing early histological and molecular changes associated with penile corporal hypoxia after cavernous nerve injury. The concept of early penile rehabilitation was developed in late nineties with a subsequent number of clinical studies supporting early pharmacologic penile rehabilitation. These studies included all available phosphodiesterase type 5 inhibitors, intracavernosal injection and intraurethral use of prostaglandin E1 and to lesser extent vacuum erectile devices. However, these studies are of small number, difficult to interpret, and often with no control group. Furthermore, no studies have proven an in vivo derangement of endothelial or smooth muscle cell metabolism secondary to a prolonged flaccid state. The purpose of the present report is a synthetic overview of the literature in order to analyze the concept and the rationale of rehabilitation program of erectile dysfunction following radical pelvic surgery and the evidence of such programs in clinical practice. Emphasis will be placed on penile rehabilitation programs after radical cystoprostatectomy, radical prostatectomy, and rectal cancer treatment. Future perspectives are also analyzed.

[The practical experience with the organization of the early rehabilitation of the patients based at the Department of Intensive Therapy, state budgetary healthcare facility "Saint Luke (V.F. Voino-Yasenetsky) Kotlas City Central Hospital"]

This article was designed to report the practical experience gained at the first stage of rehabilitation based at the Department of Intensive Therapy of a multi-disciplinary medical center with special reference to the peculiarities of organization of the work of the medical and paramedical personnel with a view to enhancing the effectiveness of early rehabilitation. These activities helped to reduce the duration of the hospital treatment of the patients staying in the intensive care unit and decrease the mortality rate. Especially much attention is given to the rehabilitative treatment of the patients presenting with myocardial infarction, ischemic and hemorrhagic stroke, severe brain injuries, and postoperative problems.