Side Effects of Cranial Remolding Orthoses: A Multi-Site Review.

ABSTRACT: Infants with deformational head shapes may be treated with a Cranial Remolding Orthosis (CRO). Risks of CROs include skin irritations and other minor side effects. It is important to examine the incidence of complications with CRO treatment to determine if the potential benefits outweigh the risks.This study retrospectively examined surveys provided by both practitioners and caregivers regarding orthotic treatment side effects and wear time at four clinics in Canada. Statistical analysis including the Chi-square test and Fisher's exact tests were performed to examine how the side effects varied by treatment site and by reported orthotic wear time.In total, 5,025 surveys about the CRO treatment of 453 patients were reviewed. The most common side effects were pressure spots, redness lasting for more than 1 hour, excessive sweat , and foul odor; however, the vast majority reported no significant issues (87.08%). Only 2.81% of surveys reported multiple side effects, which was about three times more like to happen when the CRO was reported to have fit problems. Wear time is correlated with the report of side effects; infants who wore the CRO 18 to 23.5 hours had statistically fewer side effects than those who wore the CRO for less time. The reported incidence of side effects may be artificially inflated because infants experiencing side effects are more likely to have more frequent follow-up.Overall, the side effects of CRO treatment reported in this cohort were relatively rare and minimal, indicating CRO treatment is a safe way to treat deformational head shapes.

Role of O-C2 angle in the development of dysphagia in patients with halo-vest fixation.

BACKGROUND: Dysphagia is one of the most serious complications in patients treated with a halo-vest brace. However, the cause of dysphagia development by halo-vest fixation is not yet clear. We therefore investigated the incidence of dysphagia and cervical alignment as well as clinical data from medical charts in patients treated with a halo-vest brace. METHODS: We retrospectively reviewed clinical data from the medical charts of 49 patients who had undergone halo-vest fixation. Occipito (O)-C2 angle, C2-C6 angle, and pharyngeal inlet angle were assessed by lateral plain X-rays of the cervical spine. The impacts of these parameters on incidence and severity of dysphagia were analyzed. RESULTS: Thirteen patients (32%) suffered from dysphagia during halo-vest fixation, and age and length of intensive care unit (ICU) stay were greater in the dysphagia group (p = 0.044 and 0.013, respectively) than in those who did not develop dysphagia. O-C2 angle was smaller in the dysphagia group (p = 0.016). After multivariate logistic analysis, body mass index, ICU stay, and O-C2 angle remained as independent risk factors related to incidence of dysphagia. Spearman rank correlation showed a negative correlation between ICU stay and Food Intake Level Scale (FILS) (p = 0.026), and a positive correlation between O-C2 angle and FILS (p = 0.008). CONCLUSION: This study suggested that O-C2 angle is related to both incidence and severity of dysphagia due to halo-vest fixation.

[Correction of the lumbosacral orthosis in the patients presenting with patellofemoral pain syndrome with the use of physical exercise therapy]. / Korrektsiia myshechnogo korseta poiasnichno-kresttsovogo otdela pozvonochnika u patsientov s patellofemoral'nym bolevym sindromom metodom lechebnoi fizkul'tury.

THE RATIONALE: The differential approach taking into consideration the pathogenetic aspects of the pathological condition of interest with the identification of the principal cause of disorders in the musculo-skeletal system is a topical issue in the development of the measures for the rehabilitative treatment of the affected patients. Despite a great variety of methods and guidelines currently available for the conservative treatment of the musculoskeletal system diseases, further investigations and the development of the approaches and recommendations are needed for the correction and prevention of pathobiomechanical disorders and securing the optimal motor stereotype. AIM: The objective of the present study was to improve the existing methods for the correction of the lumbosacral orthosis in the patients presenting with patellofemoral pain syndrome with the use of physical exercise therapy for the improvement of their locomotor activity. MATERIAL AND METHODS: We have undertaken a randomized controlled clinical study involving 60 outpatients. They were divided into two groups designated as the main and control ones. The inclusion criteria were the age between 18 and 35 years, the feeling of discomfort or pain in the lumbosacral region, and the combined patellofemoral syndrome. All the patients underwent the comprehensive examination of the musculoskeletal system, and evaluation of pain intensity based on the relevant visual-analogue scales, stabilometry before and after the treatment of the patients comprising the main group with the use of the combined correction and of the control patients with the application of the conventional correction methods. RESULTS: The treatment with the use of the proposed original physical exercise therapy of the patients presenting with the pain syndrome in the lumbosacral region resulted in a reduction of its intensity by 27% on the average (p<0.05) and a significant 40% decrease in the frequency of dysfunction of the thoracoabdominal diaphragm. Simultaneously, the frequency of dysfunction of the muscles stabilizing the lumbosacral spine and the lower extremity on the side of the patellofemoral complex decreased by 53.4% and 17.8% on the average, respectively. Parameters of stabilometry evaluated from the results of the 'Mishen' (Target) test and the Romberg test with eyes closed improved by 1.9 times (p<0.05) and 2.5 times (p<0.05) on the average, respectively. CONCLUSION: The study has demonstrated that dysfunction of the sacral bone and muscles in the lumbosacral spine region responsible for the formation of the pain syndrome in the lower part of the back develops in 67% of the patients presenting with the patellofemoral pain syndrome. Physiotherapy including endurance-type exercises and activation of the muscles stabilizing the lumbosacral spine and lower extremities can improve results of rehabilitation.

Systematic review of the complications associated with magnetically controlled growing rods for the treatment of early onset scoliosis.

PURPOSE: To analyse the complication profile of magnetically controlled growing rods (MCGRs) in early onset scoliosis (EOS). METHODS: This is a systematic review using PUBMED, Medline, Embase, Google Scholar and the Cochrane Library (keywords: MAGEC, Magnetically controlled growing rods and EOS) of all studies written in English with a minimum of five patients and a 1-year follow-up. We evaluated coronal correction, growth progression (T1-S1, T1-T12) and complications. RESULTS: Fifteen studies (336 patients) were included (42.5% male, mean age 7.9 years, average follow-up 29.7 months). Coronal improvement was achieved in all studies (pre-operative 64.8°, latest follow-up 34.9° p = 0.000), as was growth progression (p = 0.001). Mean complication rate was 44.5%, excluding the 50.8% medical complication rate. The unplanned revision rate was 33%. The most common complications were anchor pull-out (11.8%), implant failure (11.7%) and rod breakage (10.6%). There was no significant difference between primary (39.8%) and conversion (33.3%) procedures (p = 0.462). There was a non-statistically significant increased complication rate with single rods (40 vs. 27% p = 0.588). CONCLUSIONS: MCGRs improve coronal deformity and maintain spinal growth, but carry a 44.5% complication and 33% unplanned revision rate. Conversion procedures do not increase this risk. Single rods should be avoided. These slides can be retrieved under Electronic Supplementary material.

Influence of age and level of activity on the applicability of a walker orthosis - a prospective study in different cohorts of healthy volunteers.

BACKGROUND: Walker orthosis are frequently prescribed as they are removable to allow wound control, body care and physiotherapy and are adaptable to the soft tissue conditions. The prerequisite for successful treatment with any walker orthosis is a correct use by the patient. Therefore, the aim of this study was to investigate patients' handling of a commonly used walker. METHODS: Prospective observational study analyzing the applicability of a walker orthosis in different cohorts with varying age and level of activity. Volunteers were recruited from a mountain-biking-team (Sport), a cardiovascular-health-sports-group (Cardio) and a retirement home (Senior). The correct application was assessed following initial training (t0) and one week later (t1). Outcome parameters were an Application Score, strap tightness, vertical heel lift-off and subjective judgement of correct application. RESULTS: Thirty-three volunteers, 11 Sports group (31 ± 7a), 12 Cardio group (59 ± 11a), 10 Senior group, (82 ± 5a) were enrolled. No differences for any parameter could be observed between t0 and t1. Age showed a moderate correlation for all outcome parameters and the cohort influenced all variables. The Senior group presented significant inferior results to the Sport- and Cardio group for the Application Score (p = 0.002-p < 0.001) and strap tightness (p < 0.001). Heel lift-off was significantly inferior in the Cardio- and Senior- compared to the Sport group (p = 0.003-p < 0.001). 14% in the Sport-, 4% in the Cardio- and 83% in the Senior group achieved less than 9 points in the Application Score - which was considered insufficient. However, out of these 90% believed the application to be correct. CONCLUSIONS: The elderly cohort living in a retirement home demonstrated an impaired handling of the walker orthosis. Further, participants were incapable to self-assess the correct handling. These aspects should be respected when initiating treatment with a walker orthosis. TRIAL REGISTRATION: Retrospectively registered on the 16th of February 2018: # DRKS00013728 on DRKS.

Hand-foot-skin reaction related to use of the multikinase inhibitor sorafenib and hard orthotics.

Hand-foot-skin reaction is a distinct clinical condition arising in association with the use of multikinase inhibitors, including sorafenib. Because multikinase inhibitors are increasingly being used in children with cancer, recognition of this previously unfamiliar condition is of importance to pediatric dermatologists. We describe the diagnosis and successful treatment of a case of hand-foot-skin reaction in a child taking sorafenib for an unresectable desmoid tumor.

Garment Therapy does not Improve Function in Children with Cerebral Palsy: A Systematic Review.

AIMS: To conduct a systematic review asking, does garment therapy improve motor function in children with cerebral palsy? METHODS: A systematic review with meta-analysis was conducted to review the literature. Inclusion criteria involved the wearing of therapy suits/garments in children with cerebral palsy. The primary outcome of interest was movement related function and secondary outcomes included impairment, participation, parental satisfaction and adverse outcomes of garment wear. RESULTS: 14 studies with 234 participants were included, of which 5 studies were included for meta-analysis. Garment therapy showed a nonsignificant effect on post-intervention function as measured by the Gross Motor Function Measure when compared to controls (MD = -1.9; 95% CI = -6.84, 3.05). Nonsignificant improvements in function were seen long-term (MD = -3.13; 95% CI = -7.57, 1.31). Garment therapy showed a significant improvement in proximal kinematics (MD = -5.02; 95% CI = -7.28, -2.76), however significant improvements were not demonstrated in distal kinematics (MD = -0.79; 95% CI = -3.08, 1.49). CONCLUSIONS: This review suggests garment therapy does not improve function in children with cerebral palsy. While garment therapy was shown to improve proximal stability, this benefit must be considered functionally and consider difficulties associated with garment use.

Proper Education on Spinal Orthotics: A Way to Minimize Associated Complications.

Spinal orthotic bracing is a common modality for treating nonoperative spinal fractures with risks. This study aimed to assess the effect of an intervention on critical care nurses to improve their clinical knowledge and comfort level of managing patients. A literature review was conducted regarding common complications associated with spinal orthotics. This information was compiled and used to create a questionnaire and spinal orthotic course for nurses. Pre- and postassessments of nurses' knowledge regarding spinal orthotics were conducted. A total of 197 nurses completed the presentation. The ability to correctly identify thoracolumbosacral orthotics (TLSO), lumbosacral orthotics (LSO) and cervico-thoracic orthotics (CTO) all significantly increased. Regarding the clinical knowledge, the right answer to the question whether or not halo vest needed to be removed for cardiopulmonary resuscitation increased from 45.2% to 100% (p < .0001), and the correct answer to the question whether or not TLSO braces need to be worn at all times in patients with spinal precautions increased from 62.4% to 100% (p < .0001). Nurses reported that their comfort level of taking care of patients with spinal precautions increased from 94.4% before the presentation to 100% after the presentation. The quality improvement project seemed to improve the critical care nurses' ability to correctly identify different type of braces and their comfort level of managing patients with spinal precautions.

Implant Complications After Magnetically Controlled Growing Rods for Early Onset Scoliosis: A Multicenter Retrospective Review.

BACKGROUND: Traditional growing rods have a reported wound and implant complication rate as high as 58%. It is unclear whether the use of magnetically controlled growing rods (MCGR) will affect this rate. This study was performed to characterize surgical complications following MCGR in early onset scoliosis. METHODS: A multicenter retrospective review of MCGR cases was performed. Inclusion criteria were: (1) diagnosis of early onset scoliosis of any etiology; (2) 10 years and younger at time of index surgery; (3) preoperative major curve size >30 degrees; (4) preoperative thoracic spine height <22 cm. Complications were categorized as wound related and instrumentation related. Complications were also classified as early (<6 mo from index surgery) versus late (>6 mo). Distraction technique and interval of distraction was surgeon preference without standardization across sites. RESULTS: Fifty-four MCGR patients met inclusion criteria. There were 30 primary and 24 conversion procedures. Mean age at initial surgery was 7.3 years (range, 2.4 to 11 y), and mean duration of follow-up 19.4 months. Twenty-one (38.8%) of 54 patients had at least 1 complication. Fifteen (27.8%) had at least 1 revision surgery. Six (11.1%) had broken rods (2 to 4.5 and 4 to 5.5 mm rods); two 5.5 mm rods failed early (4 mo) and 4 late (mean=14.5 mo). Six (11.1%) patients experienced 1 episode of lack or loss of lengthening, of which 4 patients subsequently lengthened. Seven patients (13.0%) had either proximal or distal fixation-related complication at average of 8.4 months. Two patients (3.7%) had infections requiring incision and drainage; 1 early (2 wk) with wound drainage and 1 late (8 mo). The late case required removal of one of the dual rods. CONCLUSIONS: This study shows that compared with traditional growing rods, MCGR has a lower infection rate (3.7% vs. 11.1%). MCGR does not appear to prevent common implant-related complications such as rod or foundation failure. The long-term implication remains to be determined. LEVEL OF EVIDENCE: Level IV.

How Does Hyperkyphotic Early-Onset Scoliosis Respond to Growing Rod Treatment?

BACKGROUND: Growing rods (GRs) pose a higher risk of kyphosis gain while improving coronal deformity with intermittent distractions in early-onset scoliosis (EOS), but in turn, increased kyphosis may also affect GR correction outcomes. However, there is a paucity of data regarding the effect of GRs on the sagittal spinal profiles in hyperkyphotic EOS. Thus, we aim to demonstrate how hyperkyphotic EOS responds to GRs treatment. METHODS: Forty patients treated with GRs for EOS were included and categorized into a normal kyphosis (N) group [20 degrees≤thoracic kyphosis (TK)≤50 degrees] or hyperkyphosis group (K) group (TK≥50 degrees). Radiographic measurements were performed before and after the index surgery and at the last follow-up. The complications were identified and classified using the surgical complications grading system. RESULTS: The N group included 13 patients with dual GRs and 6 patients with a single GR. The K group consisted of 17 patients with dual GRs and 4 patients with a single GR. The mean age at surgery in the N and K groups was 6.2±1.8 and 6.4±2.1 years, respectively. The N and K groups, respectively, had an average number of lengthenings of 4.2±2.0 and 4.3±2.3, with an average follow-up of 4.7±1.9 and 4.6±2.1 years, respectively. In the K group, TK was markedly reduced after the index surgery and slightly increased during follow-up, whereas changes in TK in the N group were not significant. The complication rate in the K group was significantly higher than in the N group (81.0% vs. 47.4%, P=0.046). The most common implant-related and alignment-related complication in both groups was rod fracture (17.5%) and proximal junctional kyphosis (22.5%), respectively. The complication events in the N group were 5 with grade I and 5 with grade IIA, whereas in the K group there were 8 with grade I and 11 with grade IIA. CONCLUSIONS: GRs can effectively correct hyperkyphotic EOS, with the sagittal profile being successfully restored to normal range. However, hyperkyphotic EOS tends to experience more complications such as rod fracture and PJK. LEVEL OF EVIDENCE: Level III.

How does wearing a lumbar orthosis interfere with gait initiation?

The interaction between medical devices and the human body must be evaluated in standardised laboratory tests. Since wearing a lumbar orthosis is assumed to reduce lower back mobility and reinforce trunk movement control through imposed lordosis, this device is expected to affect gait initiation which requires trunk and pelvic rotations. Thirteen healthy subjects were asked to initiate gait without orthosis (control) and orthosis with or without lordosis constraints. The biomechanical parameters usually reported for gait initiation were studied and no statistically significant effects were found. Indeed, the duration of the anticipation, and execution phases and maximal instantaneous velocity of centre of gravity at the end of the first step were not modified by the experimental conditions. The lack of interference underlines the robustness of the gait initiation parameters, which therefore may lead subjects to adopt adaptive strategies to retain this invariance. Future experiments should be conducted to highlight these strategies. Practitioner Summary: The aim of this study was to investigate the effect of various lumbar orthosis characteristics on gait initiation organisation. The results, based on a dynamic analysis of balance strategies, showed that the medical device had no repercussions on movement control. Several explanations are proposed, which should be validated by future studies.

The Effect of the Cervical Orthosis on Swallowing Physiology and Cervical Spine Motion During Swallowing.

Cervical orthosis is used to immobilize the neck in various disorders such as trauma and post-operation. However, it is still uncertain how cervical orthosis restricts the degree of movement of the cervical spine during swallowing and how they affect swallowing physiology. The purpose of this study was to evaluate these issues using the Philadelphia(®) Collar. We conducted videofluorography of swallowing in 39 healthy subjects (23 men, 16 women; mean age of 34.3 years) with and without cervical orthosis. To compare the two conditions regarding the cervical spine motion, we determined the angular and positional changes of the occipital bone (C0) and each cervical vertebra (C1-C7) from the oral phase to the pharyngeal phase. Similarly, to compare swallowing physiology, we assessed the start and end times and the durations of soft palate elevation, rapid hyoid anterosuperior movement, epiglottis inversion, closure of the laryngeal vestibule, and pharyngoesophageal segment (PES) opening. Finally, we compared the transit times of contrast agent in the two conditions. The respective extensions of C1, C2, and C3 were 0.31°, 0.07°, and 0.05° (mean) with cervical orthosis, and the respective flexions of C1, C2, and C3 were 0.98°, 1.42°, and 0.85° (mean) without. These results suggested that cervical orthosis restricted the flexion of C1-C3. Analysis of swallowing physiology revealed that the average durations of hyoid anterosuperior elevation, epiglottic inversion, and PES opening were prolonged by 0.09, 0.19, and 0.05 s, respectively. In conclusion, the cervical orthosis restricted the movement of the cervical spine during swallowing and changed swallowing physiology.

Sonographic Assessment of Hip Swaddling Techniques in Infants With and Without DDH.

BACKGROUND: The purpose of this single-examination pilot study was to confirm the ability to perform hip sonography while swaddled and to ascertain whether the various swaddling techniques influenced hip position and dynamics. METHODS: Dynamic sonography was used to evaluate 30 infants in both swaddled and unswaddled positions who were being seen in clinic for suspected or documented developmental dysplasia of the hip. A "treatment group" of 16 infants (32 hips) treated in a Pavlik harness and a "nontreatment group" of 14 untreated infants (28 hips) were studied.Criteria for comparing sonographic results between swaddled and unswaddled hip positions included femoral head position, instability, and range-of-motion restriction. RESULTS: Tight swaddling with a blanket was applied in 11 "nontreatment group" cases (20 hips; in 2 cases, only 1 hip studied) and produced limited flexion and abduction. One unstable left hip dislocated when tightly swaddled. Safe swaddling technique in 12 cases (24 hips) showed no limitation of flexion and abduction of the legs and no change in stability by sonography. Commercial swaddling products appeared to mildly restrict leg motion in 14 hips, but there was no change in hip position in the "nontreatment group." However, the commercial swaddling products changed the hip position in 3 Pavlik harness cases. CONCLUSIONS: Swaddling techniques that allow a free range of leg motion may not affect hip stability in normal infants or those being treated with Pavlik harness. Swaddling with restricted leg motion increases potential for hip instability. Tight swaddling dislocated 1 unstable hip, and commercial swaddling products judged to apply only mild restriction of leg motion negatively impacted 3 cases being treated for developmental dysplasia of the hip with Pavlik harness. On the basis of this pilot study, we advise caution when swaddling infants, especially with techniques that restrict leg motion. Further study of the long-term effects of swaddling is warranted. LEVEL OF EVIDENCE: Level II.

Cervical spine overflexion in a halo orthosis contributes to complete upper airway obstruction during awake bronchoscopic intubation: a case report.

PURPOSE: We present a case of upper airway obstruction in a patient with an unstable cervical spine fracture in a halo orthosis. We also describe the mechanism by which the obstruction occurred and identify features that predispose patients in a halo orthosis to upper airway obstruction. CASE: An 81-yr-old female presenting to hospital with an unstable cervical spine fracture was scheduled for spinal fusion. She was fitted with a halo traction device in a flexed position, and an awake tracheal intubation was planned. The patient's airway was topicalized and 1 mg of midazolam was administered. Her oxygen saturation dropped, and mask ventilation was difficult and insufficient. She then became unresponsive and pulseless. Emergency release of the halo orthosis device was carried out and her neck was held in a neutral position. Mask ventilation was successfully performed and oxygenation improved. The patient's trachea was intubated via video laryngoscopy, and she was resuscitated and taken to the intensive care unit. The degree of cervical spine flexion resulting from the halo fixation was examined in subsequent radiographs, as defined by the occiput to C2 (O-C2) angle, and the oropharyngeal cross-sectional area was measured. Spine flexion from halo fixation in concert with the topical treatment and sedation predisposed the patient to acute airway obstruction. CONCLUSION: In this case, external cervical spine fixation in flexion resulted in a change to the O-C2 angle, which reduced the oropharyngeal area and predisposed to upper airway obstruction. This highlights the need for anesthesiologists to evaluate the degree of cervical spine flexion in patients with halo devices and to have the surgical team present during airway management in the event of acute airway obstruction.

Adverse Outcomes in Infantile Bilateral Developmental Dysplasia of the Hip.

BACKGROUND: It is believed that bilateral developmental dysplasia of the hip (DDH) has poorer outcomes with higher rates of avascular necrosis (AVN) and reintervention, compared with unilateral DDH. However, there is limited evidence in the literature, with few studies looking specifically at bilateral cases. METHODS: A retrospective review of 36 patients (72 hips) with >4 years of follow-up. Patient population included surgically treated DDH including late presentations and failures of conservative treatment. The dislocated hips underwent either simultaneous closed or 1 open and 1 closed, or sequential open reduction. AVN and secondary procedures were used as endpoints for analysis as well as clinical and radiologic outcomes. RESULTS: At the last follow-up, 33% of hips had radiologic signs of AVN. Those hips that had no ossific nucleus (ON) at the time of surgery had an odds ratio of developing AVN of 3.05 and a statistically significant association between the 2 variables, whereas open/closed or simultaneous/sequential reduction did not increase the risk for AVN. In addition, 45.8% of those hips required further surgery. The estimated odds ratio of needing additional surgery after simultaneous reduction was 4.04. Clinically, 79.2% of the hips were graded as McKay I, whereas radiologically only 38.8% were Severin I. CONCLUSIONS: The AVN rate in bilateral DDH treated surgically is greater than the rate noted in unilateral cases from the same institution undergoing identical protocols. There was no difference in AVN rates between simultaneous and sequential or between the first and second hip to be sequentially reduced. Presence of ON decreases the risk for AVN, suggesting that in bilateral cases, awaiting the appearance of the ON is an important tool to reduce the incidence of AVN. LEVEL OF EVIDENCE: IV.

A randomized controlled trial studying efficacy and tolerance of a knee-ankle-foot orthosis used to prevent equinus in children with spastic cerebral palsy.

OBJECTIVE: To examine whether using a knee-ankle-foot orthosis helps maintain ankle-foot dorsiflexion range of motion over time. DESIGN: A multicentre randomized controlled trial. SETTING: Two hospitals and one rehabilitation centre in the Netherlands and the USA. SUBJECTS: Children (4-16 years old) with spastic cerebral palsy who were able to walk. INTERVENTION: Use of a knee-ankle-foot orthosis, equipped with an Ultraflex ankle power unit, for at least 6 hours every other night for one year. PRIMARY OUTCOME MEASURE: ankle-foot dorsiflexion range of motion. SECONDARY OUTCOME MEASURES: ankle-foot and knee angle in gait and gross motor function. Wearing time was also measured. Measurements were taken at baseline and at 3, 6, 9 and 12 months. RESULTS: 28 children (experimental group: n=15, control group: n=13) participated in the study. 11 participants (experimental: n=4, control: n=7) did not complete all five measurements, as they needed additional treatment. No significant difference was found in the decrease of ankle-foot dorsiflexion range of motion between the experimental and control groups (difference: -1.05°, 95% confidence interval: -4.71° - 2.61°). In addition, secondary outcome measures did not show differences between groups. Despite good motivation, knee-ankle-foot orthosis wearing time was limited to a mean±SD of 3.2±1.9 hours per prescribed night due to discomfort. CONCLUSIONS: Knee-ankle-foot orthosis with dynamic ankle and fixed knee are poorly tolerated and are not beneficial in preventing a reduction in ankle-foot dorsiflexion range of motion in children with spastic cerebral palsy, at least with limited use.

Cervical collar-related pressure ulcers in trauma patients in intensive care unit.

INTRODUCTION: The application of a cervical collar (C-collar) in trauma patients can be life-saving. Previous studies, however, describe development of pressure ulcers related to C-collars. OBJECTIVE: To retrospectively compare collar-related pressure ulcers (CRPUs) occurring in trauma patients admitted to the intensive care unit wearing a C-collar before and after implementation of preventive interventions and to identify risk factors for CRPU development. METHODS: Retrospective chart review of 88 trauma patients admitted to the intensive care unit before (2006) and after (2008) implementation of preventive interventions; early C-collar removal (<24 hours) and an occipital foam ring. Data were collected in the first 14 days of admission on pressure ulcer incidence, risk factors, and preventive interventions. RESULTS: The incidence of CRPUs was 1.1%. Although risk factors were present in the sample, it was impossible to identify significant risk factors for CRPU development and explore the effect of preventive interventions. CONCLUSION: The incidence of CRPUs in this study was low. CRPUs, however, should never be accepted as an inevitable complication of cervical immobilization. To identify trauma patients at risk and to apply effective preventive interventions for CRPU development, further research is needed.

A systematic review investigating the efficacy of laterally wedged insoles for medial knee osteoarthritis.

A conservative management strategy for knee osteoarthritis is the lateral wedge insole (LWI). The theoretical basis for this intervention is to correct tibiofemoral malalignment, thereby reducing pain and optimising function. This systematic review evaluates the evidence on the effectiveness and safety of LWI for the treatment for knee osteoarthritis. A systematic review was performed, searching published (MEDLINE, AMED, EMBASE, CINAHL, Cochrane Library) and unpublished literature from their inception to August 2012. Randomised controlled trials (RCTs) were included that compared the use of LWI with a neutral insole or control intervention for people with medial compartment osteoarthritis. Risk of bias and clinical relevance were assessed, and outcomes were analysed through meta-analysis. From a total of 3,105 citations, 10 studies adhered to the a priori eligibility criteria. These included 1,095 people; 535 participants were allocated to receive LWI insoles compared to 509 in control groups. Eight per cent of papers were of high quality with low risk of bias. There was no statistically significant difference between LWI and neutral insoles for pain, function, analgesic requirement, compliance or complications (p ≥ 0.07). Those who received LWI demonstrated lower non-steroidal anti-inflammatory drug requirements (p < 0.001). To conclude, there is limited evidence to support the prescription of LWI to people with medial compartment osteoarthritis to reduce pain and increase function. However, there remains a paucity of evidence to determine whether LWI outcomes differ in subgroups of the patients, such as severe compared to mild osteoarthritis, obese patients, or whether the angle of LWI is of clinical importance.

The effect of night extension orthoses following surgical release of Dupuytren contracture: a single-center, randomized, controlled trial.

PURPOSE: To clarify the efficacy and detrimental effects of orthoses used to maintain finger extension following surgical release of Dupuytren contracture. METHODS: We conducted a single-center, randomized, controlled trial to investigate the effect of night extension orthoses on finger range of motion and hand function for 3 months following surgical release of Dupuytren contracture. We also wanted to determine how well finger extension was maintained in the total sample. We randomized 56 patients to receive a night extension orthosis plus hand therapy (n = 26) or hand therapy alone (n = 30). The primary outcome was total active extension of the operated fingers (°). Secondary outcomes were total active flexion of the operated fingers (°), active distal palmar crease (cm), grip strength (kg), and self-reported hand function using the Disabilities of the Arm, Shoulder, and Hand questionnaire (0-100 scale). RESULTS: There were no statistically significant differences between the no-orthosis and orthosis groups for total active extension or for any of the secondary outcomes. Between the first postoperative measure and 3 months after surgery, 62% of little fingers had maintained or improved total active extension. CONCLUSIONS: The use of a night extension orthosis in combination with standard hand therapy has no greater effect on maintaining finger extension than hand therapy alone in the 3 months following surgical release of Dupuytren contracture. Our results indicate that the practice of providing every patient with a night extension orthosis following surgical release of Dupuytren contracture may not be justified except for cases in which extension loss occurs after surgery. Our results also challenge clinicians to research ways of maintaining finger extension in a greater number of patients.

Cardiovascular effects of abduction shoulder sling in elderly patients; is it really safe?

OBJECTIVE: The purpose of the prospective study is to investigate the cardiovascular effects of abduction shoulder sling (ASS) in elderly patients who underwent rotator cuff surgery. METHODS: The study included 49 consecutive patients older than 50 years (mean 59.3 ± 8.2 years) who underwent arthroscopic rotator cuff repair surgery and used ASS in postoperative period. All cases underwent Holter electrocardiographic monitoring before (24 h) and after (48 h) the operation. The Holter findings were read by an experienced cardiologist and a pause of longer than 3 s and heart rate of <40 bpm was evaluated as significant bradycardia. RESULTS: One patient (61-year-old male) described feeling faint (presyncope) which was confirmed with the Holter finding of a pause more than 3 s which occurred in the day time. Two other patients (52-year-old male, and 62-year-old female) reported severe dizziness (hypotensive attack) which required admission to a general practitioner. However, Holter findings were normal in these patients. These three cases were referred to cardiology department for evaluation of carotid hypersensitivity syndrome (CSH). CSH was confirmed with tests made with provocative maneuvers in a sitting position. CSH was defined as at least 3 s of asystole (cardio-inhibitor type) during carotid massage or systolic blood pressure falling below 50 mmHg (vaso-depressor type). All three patients were obese patients and BMI was higher than 30. CONCLUSIONS: ASS may trigger CSH in short necked and obese patients by exerting mechanical stimulation to the carotid sinus. These patients should be informed about symptoms and signs of CSH and educated on the proper use of ASS and correct positioning of shoulder strap. CSH should be kept in mind in patients who present with dizziness, presyncope and palpitation during the postoperative period.