TWIST1-Reprogrammed Endothelial Cell Transplantation Potentiates Neovascularization-Mediated Diabetic Wound Tissue Regeneration

Hypovascularized diabetic nonhealing wounds are due to reduced number and impaired physiology of endogenous endothelial progenitor cell (EPC) population that limits their recruitment and mobilization at the wound site. For enrichment of the EPC repertoire from nonendothelial precursors, abundantly available mesenchymal stromal cells (MSC) were reprogrammed into induced endothelial cells (iEC). We identified cell signaling molecular targets by meta-analysis of microarray data sets. BMP-2 induction leads to the expression of inhibitory Smad 6/7-dependent negative transcriptional regulation of ID1, rendering the latter's reduced binding to TWIST1 during transdifferentiation of Wharton jelly-derived MSC (WJ-MSC) into iEC. TWIST1, in turn, regulates endothelial gene transcription, positively of proangiogenic KDR and negatively, in part, of antiangiogenic SFRP4 Twist1 reprogramming enhanced the endothelial lineage commitment of WJ-MSC and increased the vasculogenic potential of reprogrammed endothelial cells (rEC). Transplantation of stable TWIST1 rEC into a type 1 and 2 diabetic full-thickness splinted wound healing murine model enhanced the microcirculatory blood flow and accelerated the wound tissue regeneration. An increased or decreased colocalization of GFP with KDR/SFRP4 and CD31 in the regenerated diabetic wound bed with TWIST1 overexpression or silencing (piLenti-TWIST1-shRNA-GFP), respectively, further confirmed improved neovascularization. This study depicted the reprogramming of WJ-MSC into rEC using unique transcription factor TWIST1 for an efficacious cell transplantation therapy to induce neovascularization-mediated diabetic wound tissue regeneration.

Oral splints for patients with temporomandibular disorders or bruxism: a systematic review and economic evaluation

BACKGROUND

Splints are a non-invasive, reversible management option for temporomandibular disorders or bruxism. The clinical effectiveness and cost-effectiveness of splints remain uncertain.

OBJECTIVES

The objectives were to evaluate the clinical effectiveness and cost-effectiveness of splints for patients with temporomandibular disorders or bruxism. This evidence synthesis compared (1) all types of splint versus no/minimal treatment/control splints and (2) prefabricated versus custom-made splints, for the primary outcomes, which were pain (temporomandibular disorders) and tooth wear (bruxism).

REVIEW METHODS

Four databases, including MEDLINE and EMBASE, were searched from inception until 1 October 2018 for randomised clinical trials. The searches were conducted on 1 October 2018. Cochrane review methods (including risk of bias) were used for the systematic review. Standardised mean differences were pooled for the primary outcome of pain, using random-effects models in temporomandibular disorder patients. A Markov cohort, state-transition model, populated using current pain and Characteristic Pain Intensity data, was used to estimate the incremental cost-effectiveness ratio for splints compared with no splint, from an NHS perspective over a lifetime horizon. A value-of-information analysis identified future research priorities.

RESULTS

Fifty-two trials were included in the systematic review. The evidence identified was of very low quality with unclear reporting by temporomandibular disorder subtype. When all subtypes were pooled into one global temporomandibular disorder group, there was no evidence that splints reduced pain [standardised mean difference (at up to 3 months) -0.18, 95% confidence interval -0.42 to 0.06; substantial heterogeneity] when compared with no splints or a minimal intervention. There was no evidence that other outcomes, including temporomandibular joint noises, decreased mouth-opening, and quality of life, improved when using splints. Adverse events were generally not reported, but seemed infrequent when reported. The most plausible base-case incremental cost-effectiveness ratio was uncertain and driven by the lack of clinical effectiveness evidence. The cost-effectiveness acceptability curve showed splints becoming more cost-effective at a willingness-to-pay threshold of ≈£6000, but the probability never exceeded 60% at higher levels of willingness to pay. Results were sensitive to longer-term extrapolation assumptions. A value-of-information analysis indicated that further research is required. There were no studies measuring tooth wear in patients with bruxism. One small study looked at pain and found a reduction in the splint group [mean difference (0-10 scale) -2.01, 95% CI -1.40 to -2.62; very low-quality evidence]. As there was no evidence of a difference between splints and no splints, the second objective became irrelevant.

LIMITATIONS

There was a large variation in the diagnostic criteria, splint types and outcome measures used and reported. Sensitivity analyses based on these limitations did not indicate a reduction in pain.

CONCLUSIONS

The very low-quality evidence identified did not demonstrate that splints reduced pain in temporomandibular disorders as a group of conditions. There is insufficient evidence to determine whether or not splints reduce tooth wear in patients with bruxism. There remains substantial uncertainty surrounding the most plausible incremental cost-effectiveness ratio.

FUTURE WORK

There is a need for well-conducted trials to determine the clinical effectiveness and cost-effectiveness of splints in patients with carefully diagnosed and subtyped temporomandibular disorders, and patients with bruxism, using agreed measures of pain and tooth wear.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017068512.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 7. See the NIHR Journals Library website for further project information.

Injury to the inferior vena cava as a complication of ureteral splint insertion - case report

The authors describe a rare complication of ureteral stenting is the case study of a patient admitted to the hospital for congestion in the outlet system of both kidneys due to external ureteral compression by tumorous mass in the retroperitoneum. Histology confirmed the B-lymphoma of the retroperitoneum as a cause of the patients problems. The ureteral stent was perforated in the course of inserting the stent into the ureter and the end of the splint was introduced into the inferior vena cava. The patient was asymptomatic, and this complication was detected as late as on day 12 on the follow-up CT scan. Stent extraction was without complications and without bleeding.

The efficacy, safety, and cost benefits of splints for fractures of the distal radius in children: A systematic review and meta-analysis protocol

BACKGROUND

Distal radius fractures (DRFs) is one of the most common bone injuries in children, which may lead to deformity and other complications if the treatment is not prompt or appropriate. Splints external fixation is a common conservative treatment for such fractures. Therefore, we conducted a systematic review and meta-analysis to explore the efficacy, safety and cost benefits of splints in the treatment of DRFs in children.

METHODS

PubMed, Web of Science, Embase, Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov, Chinese National Knowledge Infrastructure Database (CNKI), Wanfang Database, and VIP Database were searched for eligible randomized controlled trials (RCTs). The methodological quality of the included studies and the level of evidence for results were assessed, respectively, using the risk bias assessment tool of Cochrane and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. Statistical analysis was conducted with Revman 5.3.

RESULTS

This study will analyze and integrate the existing evidence for effectiveness, safety and cost benefits of splints on DRFs in children.

CONCLUSION

The conclusion of this study will provide evidence to effectiveness, safety and cost benefits of splints on DRFs in children, which can further guide the selection of appropriate interventions.

PROSPERO REGISTRATION NUMBER

CRD42019123429.

The Superiority of Removable Contact Splints in the Healing of Diabetic Foot during Postoperative Care

OBJECTIVE

Off-loading is one of the crucial components of diabetic foot (DF) therapy. However, there remains a paucity of studies on the most suitable off-loading for DF patients under postoperative care. The aim of our study was to evaluate the effect of different protective off-loading devices on healing and postoperative complications in DF patients following limb preservation surgery.

METHODS

This observational study comprised 127 DF patients. All enrolled patients had undergone foot surgery and were off-loaded empirically as follows: wheelchair+removable contact splint (RCS) (group R: 29.2%), wheelchair only (group W: 48%), and wheelchair+removable prefabricated device (group WP: 22.8%). We compared the primary (e.g., the number of healed patients, healing time, and duration of antibiotic (ATB) therapy) and secondary outcomes (e.g., number of reamputations and number and duration of rehospitalizations) with regard to the operation regions across all study groups.

RESULTS

The lowest number of postoperative complications (number of reamputations: p = 0.028; rehospitalizations: p = 0.0085; and major amputations: p = 0.02) was in group R compared to groups W and WP. There was a strong trend toward a higher percentage of healed patients (78.4% vs. 55.7% and 65.5%; p = 0.068) over a shorter duration (13.7 vs. 16.5 and 20.3 weeks; p = 0.055) in the R group, as well. Furthermore, our subanalysis revealed better primary outcomes in patients operated in the midfoot and better secondary outcomes in patients after forefoot surgery-odds ratios favouring the R group included healing at 2.5 (95% CI, 1.04-6.15; p = 0.037), reamputations at 0.32 (95% CI, 0.12-0.84; p = 0.018), and rehospitalizations at 0.22 (95% CI, 0.08-0.58; p = 0.0013).

CONCLUSIONS

This observational study suggests that removable contact splint combined with a wheelchair is better than a wheelchair with or without removable off-loading device for accelerating wound healing after surgical procedures; it also minimises overall postoperative complications, reducing the number of reamputations by up to 77% and the number of rehospitalizations by up to 66%.

Forgotten Post Operative Nasal Splint & Oro-Nasal Fistula

of the oral cavity. It may develop as a congenital defect e.g. cleft palate, or rarely, consequent to an operative procedure like a sub muco-perichondrial resection surgery of the nasal septum. After nasal septal corrective surgery, follow up of the patient with meticulous nasal toilet and detailed examination is mandatory. In operated patients who do not report to follow up, and later on present with persisting nasal discharge, pain, nasal blockage and exsanguination must alert a clinician for any evidence of a possibly retained foreign object. Inadvertently retained nasal splints can cause long lasting morbidity due to a possible chronic sinusitis, toxic shock syndrome and palatal perforation.

Acute hand injury splinting - the good, the bad and the ugly

Injuries to the hand comprise 20% of all emergency department attendances, with an estimated annual treatment cost of over £100 million in the UK. The initial assessment and management of hand injuries is usually undertaken by junior staff, many of whom have little or no training or experience in splinting hand fractures. In the Department of Orthopaedic Hand Surgery, Morriston Hospital, we regularly observe patients presenting to the specialist hand fracture clinics having had initial management that shows no appreciation for the treatment objectives or the safe positions for splinting. This article aims to provide guidance for frontline staff on the management of hand fractures, with particular emphasis on the appropriate nonoperative care to avoid any unnecessary morbidity.

Paediatric Intravenous Splint: A Cause of Pressure Injury during Neurosurgery in Prone Position

Splint application avoids unwanted movement of limbs and kinking of intravenous catheters in infants, allowing free flow of intravenous fluids. However, if placed in contact with dependent surfaces during prone surgeries, they have the propensity to cause inadvertent pressure injuries. This occurs due to the weight of the limb and continuous friction and is augmented by a rise in the local temperature and perspiration. We wish to share our experience of such an unintentional injury caused by a paediatric intravenous splint.

PDGF-BB does not accelerate healing in diabetic mice with splinted skin wounds

Topical application of platelet-derived growth factor-BB (PDGF-BB) is considered to accelerate tissue repair of impaired chronic wounds. However, the vast literature is plagued with conflicting reports of its efficacy in animal models and this is often influenced by a wide array of experimental variables making it difficult to compare the results across the studies. To mitigate the confounding variables that influence the efficacy of topically applied PDGF-BB, we used a controlled full thickness splinted excisional wound model in db/db mice (type 2 diabetic mouse model) for our investigations. A carefully-defined silicone-splinted wound model, with reduced wound contraction, controlled splint and bandage maintenance, allowing for healing primarily by reepithelialization was employed. Two splinted 8 mm dorsal full thickness wounds were made in db/db mice. Wounds were topically treated once daily with either 3 µg PDGF-BB in 30 µl of 5% PEG-PBS vehicle or an equal volume of vehicle for 10 days. Body weights, wound contraction, wound closure, reepithelialization, collagen content, and wound bed inflammation were evaluated clinically and histopathologically. The bioactivity of PDGF-BB was confirmed by in vitro proliferation assay. PDGF-BB, although bioactive in vitro, failed to accelerate wound healing in vivo in the db/db mice using the splinted wound model. Considering that the predominant mechanism of wound healing in humans is by re-epeithelialization, the most appropriate model for evaluating therapeutics is one that uses splints to prevent excessive wound contraction. Here, we report that PDGF-BB does not promote wound closure by re-epithelialization in a murine splinted wound model. Our results highlight that the effects of cytoactive factors reported in vivo ought to be carefully interpreted with critical consideration of the wound model used.

Splints and casts: indications and methods

Management of a wide variety of musculoskeletal conditions requires the use of a cast or splint. Splints are noncircumferential immobilizers that accommodate swelling. This quality makes splints ideal for the management of a variety of acute musculoskeletal conditions in which swelling is anticipated, such as acute fractures or sprains, or for initial stabilization of reduced, displaced, or unstable fractures before orthopedic intervention. Casts are circumferential immobilizers. Because of this, casts provide superior immobilization but are less forgiving, have higher complication rates, and are generally reserved for complex and/or definitive fracture management. To maximize benefits while minimizing complications, the use of casts and splints is generally limited to the short term. Excessive immobilization from continuous use of a cast or splint can lead to chronic pain, joint stiffness, muscle atrophy, or more severe complications (e.g., complex regional pain syndrome). All patients who are placed in a splint or cast require careful monitoring to ensure proper recovery. Selection of a specific cast or splint varies based on the area of the body being treated, and on the acuity and stability of the injury. Indications and accurate application techniques vary for each type of splint and cast commonly encountered in a primary care setting. This article highlights the different types of splints and casts that are used in various circumstances and how each is applied.

The occipital and sacral pressures experienced by healthy volunteers under spinal immobilization: a trial of three surfaces

BACKGROUND

The development of a pressure ulcer is of great significance to the life-long rehabilitative management of the person with a spinal cord injury, and may indeed delay and repeatedly interfere with that process. That the period preceding admission to the specialized spinal injury unit is crucial with regard to pressure ulcer development is evident in the professional literature. Both anecdotal and empirical evidence indicates that a significant number of pressure ulcers occur as a result of management provided prior to admission, and that such ulcers are more likely to occur in those patients who have undergone a transfer process from a hospital distal to the specialist unit on a hard spinal board.

AIM

In consideration of this and of the fact that, in Ireland, the interhospital transfer of spinal injured patients has usually involved the employment of such spinal boards to achieve immobilization, this study sought to identify whether or not the pressure experienced by individuals at two anatomical locations was dependent on the support surface employed.

METHODOLOGY

Pressure under the occiput and sacrum of three healthy volunteers immobilized on three support surfaces was measured using air-filled pressure-measuring sacks. The surfaces employed were an uncovered spinal board; a spinal board with inflatable raft devise; and a full-body vacuum splint.

DISCUSSION

Marked reductions in pressure were measured when using the inflatable raft and the vacuum mattress. The results of this study will provide a basis for a larger study and, through that, the formulation of recommendations for standardized practice along a national care pathway.

Rapid onset bilateral palmar keratoderma in a psoriasis patient wearing orthopaedic hand splints

A 37-year-old man with a history of chronic stable plaque psoriasis fractured both hands during a fall on his outstretched hands. Ten days later, following surgery and the application of tight fitting orthopaedic hand splints, the splints were removed because of a 7-day history of painful and pruritic palms. It was evident that the injury to his hands and the firm application of his splints had resulted in a dramatic flare of his psoriasis. This manifested in two clinical forms that he had not developed previously. He had a strikingly symmetrical palmar keratoderma that had köbnerized maximally in the regions where the splints apposed his palms firmly. In addition, he had pustular psoriasis affecting the fingertips of both hands. After removal of the splints he responded to a combination of oral acitretin, and 6% coal tar and 6% salicylic acid in aqueous cream applied topically.

Bone setters' gangrene

BACKGROUND

Gangrene usually supervenes following prolonged pressure of tight splintage by traditional bone setters (TBS) in the process of treating fractures. However, various complications such as blisters, pressure, sores, Volkmann's ischaemia/contracture, Crush syndrome and pregangrene occur by the same mechanism depending on degree of pressure and duration of splintage of the limb.

METHOD

This is a guest lecture delivered to resident doctors. Literature search was done through the internet and some unlisted journals and texts. Experiences of various institutions in Nigeria and abroad concerning bone setters' gangrene were elucidated. Attempt was made to broaden the concept of bone setters' gangrene to include all complications that arise through the same mechanism. The aetiology, pathophysiology and treatment of the vsrious conditions were highlighted and the solution and way-forward suggested.

RESULT

The various health institutions recorded unacceptably high percentage of amputations secondary to bone setters' gangrene e.g. Zaria--57% to 63%, Jos--60-77.8%. Enugu recorded mortality of 26.7% while Banjul had 11.1% mortality in their series. Nearly all the series suggested education of bone setters as a solution.

CONCLUSION

A different approach to limiting bone setters' gangrene is suggested such as condemning bone setters' practice and expanding orthopaedic care.

Re-emphasising the efficacy of the multi-purpose, self-adjustable, aeroplane splint for the splinting of axillary burns

This article re-emphasises the efficacy of the previously described multi-purpose, self-adjustable, aeroplane splint for the splinting of axillary burns. This superior to the commonly used contoured splint for various reasons namely (i) its usability during the acute burn care rehabilitation, (ii) its cost effectiveness, (iii) its durability, and (iv) its strength. Above all due to its easy maneuverability this splint provides easy accessibility around environmental barriers. Though we acknowledge that there is a possibility of 'chord of circle' development due to the use of this splint, we have been successful in preventing such a complication simply by prescribing pressure garment concomitantly with this splint. Thus this article highlights the efficacy of earlier described multi-purpose, self-adjustable, aeroplane splint for the splinting of axillary burns.

Complications arising from the use of removable wrist splints: even the simplest technology has its hazards

Wrist braces with, and without, thumb extensions (so-called "Futura" splints) were introduced into the Emergency Departments of Cork City Hospitals in July 2001. Constructed of rigid aluminium with a soft synthetic covering and Velcro strapping, they are designed for use in less severe upper limb injuries (such as wrist or thumb sprains or clinically suspected scaphoid fractures with normal X-rays). Their introduction coincided with a relaxation of the guidelines for immobilizing suspected scaphoid fractures.

The prevention of traditional bone setter's gangrene

A two-year retrospective survey in southern Ethiopia revealed that 49 amputations had been performed, 25 of which were for gangrene following tight splintage applied by traditional bone setters. The aim of this study was to determine if it was possible to reduce this incidence of gangrene by offering one-day instructional courses to bone setters. In ten separate one-day courses 112 tradition healers attended. In addition, two-day courses were given to local health assistants, who also received written instructions for the safe care of fractures. A two-year prospective study revealed a marked reduction in amputations, from 49 to 25, with only seven rather than 25 being required for gangrene. We found that it is possible to educate traditional healers so that fewer gangrenous limbs require to be amputated.

Comparative analysis of the effectiveness of the mandibular angle fracture treatment methods

425 patients with mandibular angle fractures were treated at the Hospital of Kaunas University of Medicine (HKUM) Clinic of Maxillo-Facial Surgery. Treatment included the application of closed fracture fragments fixation methods (wire splint fixation, and Kirschner wire osteosynthesis), and methods of open fixation--osteosynthesis using the supra-periosteal miniplate, and osteosynthesis using supra-osseous Zes Pol plate (the latter method was modified by the authors). Relative computerized densitometry showed that closed fixation methods result in a faster healing of fractures. The findings of the pain threshold testing showed that open fixation methods more severely damage the function of the lower alveolar nerve. Using closed fixation methods, osteomyelitis occurred in 5.3% of cases, while using open fixation methods--in 15.3% of cases. Thus, the authors of the article maintain that when mandibular angle fractures, in the presence of suitable conditions, closed fracture fragments fixation methods should be given a priority.

'I know my body, I've lived in it all my life': therapy experiences of young people with disabilities

Remedial surgery and other treatments are a common feature of disabled childhoods. These treatments are founded on notions of a normal:abnormal divide in which the task of health professionals is to bring such young people as close to societal concepts of normal as possible. Working with new paradigm disability and childhood research young people who are growing up with a disability have been able to contribute to our understanding from their perspectives. The young people identify the physical, social and emotional implications of remediation and identify a personal cost:benefit ratio. Questions of outcomes, definitions of success, and 'how much remediation is enough?' further complicate this. What may be perceived as a successful outcome by the health professional may not result in any functional gain for the young person. In discourses heavily influenced by health professional and parent perceptions the inclusion of the young people themselves contributes an additional dimension to our understanding.

Nasal ciliary beat after insertion of septo-valvular splints

OBJECTIVE

At present, endonasal paraseptal splints are devices frequently employed in rhinosurgery. We evaluated the local tolerance of a newly shaped device, the Guastella/Mantovani splint (G/M-SVS), with respect to the physiological mechanism of mucociliary clearance.

STUDY DESIGN AND SETTING

The study involved 20 patients who underwent septoplasty and/or turbinoplasty or other nasal surgical procedures. A sample of ciliated cells was obtained by nasal brushing and was examined ex vivo to determine the ciliary beat frequency (CBF) and morphology, before and 15 days after surgery.

RESULTS

Before surgery the mean CBF was 10.87 Hz +/- 0.56 Hz and when splints were removed it was 10.25 Hz +/- 1.9 Hz. Morphological evaluation of the ciliary motion after surgery demonstrated a normal, coordinated beat.

CONCLUSIONS

The G/M-SVS does not appear to interfere with the physiological mechanism of mucociliary clearance since CBF remain within a normal range.

SIGNIFICANCE

This is the first study that demonstrates an optimal tolerability and safety of the septo-valvular splints on nasal mucosa.

Femur fracture immobilization with traction splints in multisystem trauma patients

OBJECTIVE

To evaluate the frequency of concomitant injuries that can complicate and/or contraindicate the use of traction splints (TSs) for femur fracture immobilization (FFI) in a population of multisystem trauma patients.

METHODS

This was a descriptive, prospective study utilizing a data collection tool to identify patients with multisystem trauma for which a TS was in place for FFI. Patient care records and follow-up diagnoses were reviewed to identify patients with positive femur fracture(s) who concurrently had injuries that can complicate and/or contraindicate TS use. Injuries considered to complicate or contraindicate traction splint use include 1) pelvic injury, 2) patellar fracture or ligamentous knee injury, and 3) tibia/fibula fracture.

RESULTS

Forty patients were identified as having a TS in place with an underlying diagnosis of multisystem trauma. All 40 had follow-up diagnosis information available, 39 of which were positive for femur fracture on the side of the extremity on which the splint was placed, or bilaterally. The incidence of complicating and/or contraindicating injuries was 38%.

CONCLUSION

Traction splints are commonly used in the prehospital and transport setting for immobilization of femur fractures. There are limited data available on the benefit of traction splint use for femur fracture in the prehospital or transport environment. This study identified that concomitant injuries that complicate and/or contraindicate traction splint use are common.

Randomized crossover trial of two treatments for sleep apnea/hypopnea syndrome: continuous positive airway pressure and mandibular repositioning splint

Mandibular repositioning splints (MRSs) and continuous positive airway pressure (CPAP) are used to treat the sleep apnea/hypopnea syndrome (SAHS). There are some data suggesting that patients with milder symptoms prefer MRS, but there are few comparative data on outcomes. Therefore, we performed a randomized crossover trial of 8 weeks of CPAP and 8 weeks of MRS treatment in consecutive new outpatients diagnosed with SAHS (apnea/hypopnea index [AHI] >or= 5/hour, and >or= 2 symptoms including sleepiness). Assessments at the end of both limbs comprised home sleep study, subjective ratings of treatment value, sleepiness, symptoms, and well-being, and objective tests of sleepiness and cognition. Forty-eight of 51 recruited patients completed the trial (12 women; age [mean +/- SD], 46 +/- 9 years; Epworth 14 +/- 4; median AHI, 22/hour; interquartile ratio [IQR], 11-43/hour). Significant (p <or= 0.01) differences between MRS and CPAP were observed for 7 of 21 variables (effect sizes, 0.3-0.6 SDs), all favoring CPAP, including AHI (15 +/- 16 and 8 +/- 6/hour, respectively), effectiveness rating, symptoms, Epworth (12 +/- 5 and 8 +/- 5, respectively), functional outcomes of sleepiness questionnaire, short-form 36 health survey mental component, and health transition scores. Objective sleepiness, cognitive performance, and preference for treatments were not different. In patients experiencing a mild form of the syndrome (AHI < 15, n = 18), symptoms, treatment efficacy and satisfaction, and subjective sleepiness were also better with CPAP than with MRS (effect sizes, 0.7-1.1 SDs). These results do not support these MRS devices as first-line treatment for sleepy patients with SAHS.

Is routine splintage following primary total knee replacement necessary? A prospective randomised trial

It was hypothesised that routine splintage following primary total knee replacement has no affect on flexion deformity and offers no benefit over simple wool and crepe. Fifty-five patients undergoing primary total knee replacement were entered into a prospective study. The patients were randomly assigned to two groups: The first group was rehabilitated without a splint and the second received an adjustable semi-rigid extension splint (Richards splint) for the first 48 h after surgery. Range of motion measurements were recorded pre-operatively and at 2 days, 1 week and 3 months post-operation by a research nurse blinded to the allocation. No statistically significant difference in flexion deformity was found at any stage (P>0.5). No difference was found in general or wound complications, or requirement for blood transfusion, and the post-operative stay was equal in the two groups. We conclude that routine use of a semi-rigid splint following primary total knee replacement has no advantage over simple wound dressings.

The use of knee splints after total knee replacements

The aim of this randomised prospective study was to establish whether the use of knee splints following total knee replacement is necessary. The study included 81 patients undergoing total knee replacement who were randomised into a 'splint' and a 'no splint' group post-operatively. The following parameters were recorded: The range of movement pre-operatively, 5 days post-operatively and 6 weeks post-operatively; the length of time to straight leg raise; the blood drained from the wound; and the amount of post-operative analgesia required. We found that patients in the 'no splint' group achieved significantly greater flexion at 5 days and 6 weeks post-operatively but drained significantly more blood from the wound. Transfusion requirements were similar in the two groups. There was no other significant difference in the parameters measured between the two groups. In conclusion we found no evidence to advocate the use of knee splints following total knee arthroplasty.

Dental materials and magnetic resonance imaging

The objective of this investigation was to evaluate the reaction of selected dental materials in the magnetic field of a magnetic resonance imaging device to determine a possible health risk. The following dental materials were tested in vitro during magnetic resonance imaging: 15 dental alloys, four dental implants, one surgical splint and two wires for fixation of maxillofacial fractures. Possible artefacts (corresponding with magnetic properties), heating and force effects were tested. Results concerning movement and heating were in agreement with the literature. The artefacts seen were significant: for the surgical splint, a spherical artefact with a diameter of 55 mm; for the wires, up to 22 mm; and for the dental blade implant, an artefact of 28 x 20 mm. The results of our tests of selected dental appliances indicate that their presence in the human organism is safe for patients undergoing magnetic resonance imaging procedures. The presence of artefacts can substantially influence the magnetic resonance imaging results.

[Changes in the local nonspecific immune response to post-traumatic inflammation during treatment]

Clinical investigation have been done in adult patients with broken mandible during 3 weeks of conservative treatment with aluminum splints (1st group, n = 17) or steel splints (2nd group, n = 16) in comparison with health adults (control group, n = 18). The neutrophil emigration into alterative locus and their degranulation as well as phagocytic activity of peripheral blood neutrophils were tested. It was found that aluminum splint application caused the intensive inflammation and then the depression of local host defense reactions. Treatment with steel splints did not lead to neutrophil function depletion or to hyper-intensification of inflammatory reaction in patients. The increased values of neutrophil reactions were normalized in this group at the final period of the treatment. The examined trial ensures our accurate method in treatment of patients with broken mandible. The determination of local host defense state may be proposed as preferable simple express-method of evaluation of immune status, treatment efficiency and prognosis in these patients.

Mandibular advancement splint improves indices of obstructive sleep apnoea and snoring but side effects are common

AIM

To assess the efficacy of a mandibular advancement splint (MAS) in the treatment of obstructive sleep apnoea syndrome (OSAS).

METHODS

Nineteen patients using a MAS for symptomatic OSAS underwent polysomnography, with MAS use randomised to one half of the night. Indices of snoring and OSAS were compared. Side effects, compliance and treatment response were evaluated by questionnaire.

RESULTS

Use of the MAS improved total respiratory disturbance index (RDI) from 22.2 +/- 19.8 (SD) events per hour to 16.5 +/- 21.4/hr (p = 0.03), supine RDI (30.8 +/- 23.8/hr to 18.8 +/- 22.1/hr, p = 0.01), arousal index (25.2 +/- 18.9/hr to 19.3 +/- 14.2/hr, p = 0.01) and snoring intensity (52.7 +/- 4.1 to 50.7 +/- 2.7 dB, p = 0.02) but not total snore frequency (p > 0.05). Using polysomnographic criteria, MAS treatment was completely successful in four (21%) patients, partially successful in ten (52.6%) and a failure in five (26.3%). Treatment over a median of 6.5 weeks (range 2-48) was perceived as beneficial by ten of eleven partners. Fifteen patients (79%) reported side effects, 9 (46%) did not use the device every night and four (21%) used the device less than three nights per week.

CONCLUSION

The use of the MAS resulted in significant reductions in indices of OSAS and snoring. However, a significant number of patients had difficulty tolerating and regularly using the device.

Braces for postoperative bandage after otoplasty

Postoperative bandaging following otoplasty is commonly used. It is also frequently perceived as cumbersome and often lost by patients. Simple splinting potentially offers a less obtrusive postoperative ear fixation. Braces consisting of silicone-coated steel wire have been designed for simpler and lighter postoperative fixation. The braces replaced conventional bandaging. The initial favorable experience with the ear braces is described following the otoplasty of 17 ears. It is suggested that the use of splints may improve the immediate postoperative appearance, and subsequently compliance for patients. However, the long-term effect of postoperative bandaging remains unknown.

Splinting or surgery for carpal tunnel syndrome? Design of a randomized controlled trial [ISRCTN18853827]

BACKGROUND

Carpal tunnel syndrome is a common disorder, which can be treated with surgery or conservative options. However, there is insufficient evidence and no consensus among physicians with regard to the preferred treatment for carpal tunnel syndrome. Therefore, a randomized controlled trial is conducted to compare the short- and long-term efficacy of surgery and splinting in patients with carpal tunnel syndrome. An attempt is also made to avoid the (methodological) limitations encountered in earlier trials on the efficacy of various treatment options for carpal tunnel syndrome.

METHODS

Patients of 18 years and older, with clinically and electrophysiologically confirmed idiopathic carpal tunnel syndrome, are recruited by neurologists in 13 hospitals. Patients included in the study are randomly allocated to either open carpal tunnel release or wrist splinting during the night for at least 6 weeks. The primary outcomes are general improvement, waking up at night and severity of symptoms (main complaint, night and daytime pain, paraesthesia and hypoesthesia). Outcomes are assessed up to 18 months after randomization.

Good results after treatment with the Frejka pillow for hip dysplasia in newborns: a 3-year to 6-year follow-up study

Because there is no consensus with regard to the efficiency of the Frejka pillow in the treatment of hip joint dysplasia in newborns, the aim of the present study was to evaluate our results with this device. During the 3-year period 1988 to 1990, the Frejka pillow was used in 108 newborns with clinically unstable hips verified by ultrasonography. There were three treatment failures (2.8%), defined as infants who needed additional treatment with an abduction splint or hip-spica cast. Avascular necrosis of the femoral head occurred in one patient (0.9%). At an age of 3 years to 6 years, 85 of the children attended a follow-up examination. An intoeing gait was observed in 17% and slightly reduced hip mobility in 20% of the patients. Compared with normal children, the patients had somewhat lower coverage of the femoral head by radiography, indicated by a lower centre-edge angle and a higher migration percentage, but the coverage was within the normal range in all cases. The mean anteversion angle was larger than that of normal children but only three patients had abnormally high anteversion angles. In conclusion, the results with the Frejka pillow were good, with few treatment failures and complications, and it is the most simple abduction device for the parents to handle. More rigid devices like the von Rosen splint seem to involve a slightly lower failure rate, but a higher risk of avascular necrosis. Therefore, we recommend the Frejka pillow when treatment is started within a few days of birth.

The impact of using intranasal splints on morbidity and prevalence of adhesions

OBJECTIVE

To study the effect of using intranasal splints for prevention of adhesions and to assess the morbidity associated with their use.

METHODS

A retrospective study based on 2 tertiary hospitals from 1988-1995. One hundred and fourteen patients were divided into 2 groups. Group one with splints and group 2 without. The splints were used for 10 days and nasal toilet was carried out twice. Score of adhesions, perforation, bleeding, pain, crusting, and septum position were recorded.

RESULTS

Adhesions in both groups were almost the same as well as septum medialization and perforation scores. Pain and crusting were more common in the splinted group (p-value <0.001).

CONCLUSION

The use of intranasal splints should be individualized. Nasal irrigation is of importance to prevent crusting. The morbidity associated with intranasal splints should be considered before use.

[Tension force in dynamic splints made of neoprene]

Dynamic splints are the most difficult ortheses to make. Unrestricted finger joint mobility is usually prevented by the size of their components. Ortheses made out of neoprene material have the advantage of being pliable and at the same time can be constructed as dynamic splints. Neoprene material elasticity allows conforming it into a tube that can be fitted over a finger, spreading uniform pressure. A traction slip can be cemented to the neoprene finger tube. With neoprene splints, lever arms are more efficient. Their tubular design applies and spreads traction and countertraction forces in all directions. Neoprene material's elasticity contributes in reducing edema formation as well as distributes forces applied to the finger over a large area. The risk of excessive pressure is the only drawback of an elastic tubular design, it may cause pain and tissue ischemia. A meticulous tailoring prevents this potential risk.

Short-term effects of dynamic lycra splints on upper limb in hemiplegic patients

OBJECTIVE

To assess acceptability, effects on swelling, resting posture, spasticity, and active (AROM) and passive range of motion (PROM) of individually tailored upper limb Lycra garments, designed as dynamic splints to exert directional pull on certain limb segments, when worn for 3 hours by hemiplegic patients.

DESIGN

Crossover trial.

SETTING

Outpatient and inpatient rehabilitation center.

PATIENTS

Convenience sample of 16 patients with hemiparesis and upper limb spasticity caused by a stroke more than 3 weeks before the study.

INTERVENTIONS

Assessments performed at the start and end of a 3-hour period during a standard rehabilitation day when the patients were and were not wearing the garment.

MAIN OUTCOME MEASURES

(1) Comfort assessed by questionnaire; (2) circumference of each limb segment; (3) resting posture at elbow and wrist; (4) spasticity at shoulder, elbow, and wrist using the Tardieu scale; and (5) AROM and PROM at shoulder, elbow, and wrist measured using a goniometer; (6) elbow proprioception using McCloskey's method; (7) visual neglect syndrome using the line bisection test. Differences between changes occurring with and without the garment were compared using Wilcoxon's signed rank test for ordinal variables (spasticity grading) and Student's t test for continuous variables (all other data).

RESULTS

During 3 hours, garments worn on the arm by patients with hemiplegia (1) were comfortable, (2) improved wrist posture and reduced wrist and finger flexor spasticity, (3) reduced swelling in patients with swollen limbs (digit circumference decreased by 4%; p<.01), (4) improved PROM at shoulder (mean increase in range, 4.1 degrees +/- 13.0 degrees per shoulder movement; p<.01); and (5) impaired ability to flex fingers (range of voluntary flexion of digit III reduced from 107.3 degrees +/-79.6 degrees to 91.4 degrees +/-74.1 degrees; p<.05).

CONCLUSION

Lycra garments, designed to produce continuous stretch of spastic muscles when worn for several hours each day, have rapid splinting and antispastic effects on wrist and fingers in patients with hemiplegia. These garments may help severely affected patients with major spasticity or painful swollen limbs.

Thumb digital neuropathy caused by splinting

Healthcare professionals are currently faced with a great variety of splints and splinting materials. Choices range from prefabricated products to custom splints made on-site from plaster, orthoplast, or fiberglass. In addition to providing immobilization to maintain a particular posture, a splint must protect important soft tissues. Patients with hand or wrist injuries often receive a prefabricated metal cock-up wrist splint in emergency departments. Complications from splints are not uncommon but are infrequently reported. We report a case in which a metal wrist cock-up splint caused compression of the thumb ulnar digital nerve. Preventive measures for such complication are included.

The application of the Landstuhl frame for air evacuation of patients with femur fractures

The use of traction to transport patients with femur fractures is well accepted. This paper describes step-by-step the construction of a traction device suitable for use on military aircraft. This "Landstuhl frame" is easily constructed using materials readily available. It is quick and effective for the transportation of patients with lower extremity fractures.

Major amputations in Nigeria: a plea to educate traditional bone setters

A study was made of 100 major amputations performed on 96 patients in two regional hospitals in a 10-year period in Nigeria. The objective of the study was to evaluate the outcome of major amputations in Nigeria. The median age of patients was 30 years with male to female ratio 3:1. Ninety of the 100 major amputations involved the lower limbs with the above-the-knee/elbow-the-knee ratio of 0.5. Trauma was the leading indication for 70 amputations, of these 60 were iatrogenic resulting from mismanaged fractures by the traditional bone setters. The non-traumatic indications were: diabetic limb gangrene (20); bone malignancies (9); and vascular insufficiency (1). Provisional amputation was offered in 60 cases, of these 10 had reamputation. There were eight (8.5%) mortalities. The functional outcome for this group was discouraging. Only 25 amputees affording successful prosthetic fitting and social rehabilitation. Major amputation in Nigeria foreshadows a dismal existence and emphasizes the need for health policies which are effective in controlling the risk factors.

Avascular necrosis and the Aberdeen splint in developmental dysplasia of the hip

Between January 1987 and December 1988 there were 7575 births in the Swansea maternity unit. Of these 823 (10.9%) were considered to be at 'high risk' for developmental dysplasia of the hip (DDH). Static ultrasound examination was performed in each case and the results classified on the basis of the method of Graf. A total of 117 type III-IV hips in 83 infants was splinted using the Aberdeen splint. Radiographs of these hips were taken at six and 12 months. Hilgenreiner's measurements of the acetabular angle were made in all cases and the development of the femoral capital epiphysis was assessed by measuring the epiphyseal area. The effect of splintage on the acetabular angle and the epiphyseal area between the normal and abnormal splinted hips was compared. Radiographs of 16 normal infants (32 normal unsplinted hips) were used as a control group. This cohort has now been followed up for a minimum of nine years. There have been no complications as a result of splintage. The failure rate was 1.7% or 0.25 per 1000 live births. No statistical difference was found when comparing the effect of splintage on the acetabular angle and epiphyseal area between normal and abnormal splinted hips and normal unsplinted hips. Our study has shown that while the Aberdeen splint had a definite but small failure rate, it was safe in that it did not produce avascular necrosis. The current conventional view that a low rate of splintage is always best is therefore brought into question if the Aberdeen splint is chosen for the management of neonatal DDH.

Nasal splints, revisited

A study was carried out to compare the effectiveness of nasal splints (in preventing intranasal adhesions) with the morbidity associated with their use in nasal surgery. One hundred and ten patients undergoing a routine nasal operation were randomly allocated into two equal groups, one with splints and the other without. Post-operative pain and discomfort was assessed by a visual analogue scale at 48 hours and a week following surgery when either nasal suction (non-splinted group) or removal of splints was carried out. All patients were examined after six weeks for development of adhesions. Results showed that there was no significant difference in the incidence of adhesions between the splinted and non-splinted patient groups. However, the patients with splints had significantly more pain and nasal discomfort when assessed one week after surgery. It is concluded that the morbidity associated with nasal splints does not justify their use in routine nasal surgery if the aim is to prevent nasal adhesions, but they may still be indicated for enhancing the stability of the septum following septoplasty.

Traditional bone setter's gangrene

Traditional bone setter's gangrene (TBSG) is the term we use to describe the sequelae sometimes seen after treatment with native fracture splints. Twenty five consecutive complications were recorded in 25 patients aged between 5-50 years with a median age of 10 years. The major complication of the native fracture splint treatment was distal limb gangrene necessitating proximal amputations in 15 cases.

Traditional bone setting: a risk factor in limb amputation

Over a period of ten years a total of 225 limb amputations were performed at Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. The major pathology leading to amputation was trauma and gangrene due to inappropriate splintage of fractures (63.2%) by traditional bone setters. The male:female ratio was 4.6:1 and the ages ranged from two to 85 years. The commonest level of amputation was above elbow amputation (26.6%) followed by above knee amputation. Most of these amputations are preventable if the traditional bone setters avail themselves for training to recognise the impending features of limb ischaemia as well as the introduction of some refinement into their practice.

Neoprene splinting: dermatological issues

Occupational therapists are expanding their use of custom and commercial soft splints fabricated from neoprene (polychloroprene), but little has been written regarding dermatological issues associated with this material. Skin contact with neoprene poses two dermatological risks: allergic contact dermatitis (ACD) and miliaria rubra (i.e., prickly heat). Allergic reaction to neoprene is generally ascribed to the accelerants used to manufacture the man-made rubber, specifically thiourea compounds and mercaptobenzothiazole (MBT). Symptoms of neoprene-related ACD include itching, skin eruptions, swelling, and hemorrhages into the skin. Miliaria rubra creates small, red, elevated, inflammatory papules and a tingling, burning sensation. Although neoprene hypersensitivity is rare, its incidence may grow as neoprene becomes a more commonly used material. It is recommended that therapists screen patients for a history of dermatological reactions to neoprene or other materials containing thiourea compounds or MBT and educate patients to discontinue splint use if dermatological symptoms develop. Therapists are also encouraged to notify splint manufacturers regarding all ACD reactions.

[The effect of splints on the status of the hard dental tissues and periodontium in patients with jaw fractures]

Effects of metal splints on the hygienic status of the oral cavity and status of dental hard tissues and the periodontium were studied in 30 patients with fractures of the jaws during the first days after treatment with splints and in the postimmobilization period. Sixty-seventy days after the splints were removed, the hygienic status of the oral cavity was worse than in normal subjects; moreover, the intensity of caries increased and the periodontal status deteriorated.