Relationship of preoperative neurologic score with intervals to regaining micturition and ambulation following surgical treatment of thoracolumbar disk herniation in dogs.

OBJECTIVE To estimate the times required for dogs to regain micturition and ambulation following surgical treatment for thoracolumbar Hansen type I intervertebral disk extrusion (IVDE) and determine whether these variables were associated with preoperative modified Frankel score (MFS). DESIGN Retrospective case series with nested cohort study. ANIMALS 54 dogs weighing < 20 kg (44 lb) that were surgically treated for Hansen type I IVDE at a referral hospital between January and December 2015. PROCEDURES Medical records and CT and MRI data were reviewed. Information was collected regarding dog signalment, type and duration of clinical signs, preoperative MFS, degree of spinal cord compression, type of medical and surgical treatment provided, and intervals from surgery to regaining micturition and ambulation (outcomes). Collected data were evaluated for correlations with outcomes. RESULTS Mean ± SD interval from surgery to regaining micturition was 4.1 ± 4.4 days, and mean interval from surgery to regaining ambulation was 13.8 ± 25.1 days. These intervals differed significantly. Significant negative correlations with MFS were identified for interval to regaining micturition (r = -0.63) and interval to regaining ambulation (r = -0.64). No other correlations with outcome were identified. CONCLUSIONS AND CLINICAL RELEVANCE The amount of time required for dogs to regain micturition and ambulation following surgery for thoracolumbar IVDE was correlated with preoperative severity of clinical signs, as reflected by preoperative MFSs. This information should be useful for pre- and postoperative decision-making and setting of expectations for owners of and clinicians treating affected dogs.

Minocycline in leprosy patients with recent onset clinical nerve function impairment.

Nerve function impairment (NFI) in leprosy may occur and progress despite multidrug therapy alone or in combination with corticosteroids. We observed improvement in neuritis when minocycline was administered in patients with type 2 lepra reaction. This prompted us to investigate the role of minocycline in recent onset NFI, especially in corticosteroid unresponsive leprosy patients. Leprosy patients with recent onset clinical NFI (<6 months), as determined by Monofilament Test (MFT) and Voluntary Muscle Test (VMT), were recruited. Minocycline 100mg/day was given for 3 months to these patients. The primary outcome was the proportion of patients with 'restored,' 'improved,' 'stabilized,' or 'deteriorated' NFI. Secondary outcomes included any improvement in nerve tenderness and pain. In this pilot study, 11 patients were recruited. The progression of NFI was halted in all; with 9 out of 11 patients (81.82%) showing ?restored? or ?improved? sensory or motor nerve functions, on assessment with MFT and VMT. No serious adverse effects due to minocycline were observed. Our pilot study demonstrates the efficacy and safety of minocycline in recent onset NFI in leprosy patients. However, larger and long term comparative trials are needed to validate the efficacy of minocycline in leprosy neuropathy.

Nonoperative Versus Operative Treatment of Displaced Ankle Fractures in Diabetics.

BACKGROUND: Diabetes is a risk factor for complications related to displaced ankle fractures. Limited literature exists comparing complication rates in nonoperative versus operative treatment of displaced ankle fractures in diabetics. No study has highlighted the natural history of nonoperative treatment of displaced ankle fractures in diabetics. METHODS: We retrospectively reviewed all adult ankle fractures from September 2011 through December 2014. Inclusion was limited to ambulatory adults (>18 years) with closed, displaced (widened mortise) ankle fractures with diabetes mellitus. Nonoperative treatment consisted of closed reduction and casting. Fractures were classified according to the Lauge-Hansen and AO-Weber classification systems. All operative fractures underwent open reduction internal fixation (ORIF) within 3 weeks of injury. Functional outcomes and complication rates were compared. Of 28 displaced diabetic ankle fractures, 20 were treated nonoperatively (closed reduction and casting) and 8 operatively (ORIF within 3 weeks of injury). Mean follow-up was 7 months (range 3-18 months). RESULTS: Age, insulin-dependent diabetes, and AO type B fracture rate were similar in nonoperative and operative cohorts, but fracture dislocation rate was significantly higher among operative fractures (87.5% vs 40%; P = .04). Nonoperative treatment was associated with a 21-fold increased odds of complication compared with operative treatment (75% vs 12.5%, OR 21.0, P = .004). Complication rate following unintended ORIF for persistent nonunion or malunion in nonoperatively treated patients was significantly greater compared with immediate ORIF (100% vs 12.5%, P = .005). CONCLUSION: Nonoperative treatment of displaced diabetic ankle fractures was associated with unacceptably high complication rates when compared to operative treatment. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

[SHORT-TERM EFFECTIVENESS OF TightRope SYSTEM FOR TREATMENT OF SYNDESMOTIC TIBIOFIBULAR DIASTASIS].

OBJECTIVE: To summarize the short-term effectiveness of TightRope system for the treatment of syndesmotic tibiofibular diastasis. METHODS: Between June 2013 and June 2015, 23 patients with syndesmotic tibiofibular diastasis were treated by TightRope system, including 15 males and 8 females with an average age of 32.3 years (range, 16-63 years). Injury was caused by sports in 13 cases, by traffic accident in 6 cases, and by falling from height in 4 cases. The locations were the left side in 13 cases and the right side in 10 cases. The time from injury to operation was 6 hours to 12 days (mean, 3.8 days). According to Lauge-Hansen classification, 13 cases were rated as supination-external rotation type, 7 cases as pronation-abduction type, and 3 cases as pronation-external rotation type; according to Weber classification, 5 cases were rated as type A, 11 cases as type B, and 7 cases as type C. RESULTS: The mean operative time was 68.1 minutes (range, 48-93 minutes); the mean intraoperative blood loss was 70.3 mL (range, 20-150 mL); and the mean hospitalization days were 7 days (range, 5-13 days). Superficial local skin necrosis occurred in 6 cases, and primary healing of incision was obtained in the others. All patients were followed up 8-30 months (mean, 16.4 months). X-ray films showed bone union was achieved within 6-12 weeks (mean, 9.4 weeks). No related complications of reduction failure and re-fracture occurred. The internal fixators were removed at 10-18 months postoperatively (mean, 13.3 months). According to American Orthopaedic Foot and Ankle Society (AOFAS) score for ankle function evaluation, the results were excellent in 19 cases and good in 4 cases at last follow-up. CONCLUSIONS: TightRope system is a good method to treat syndesmotic tibiofibular diastasis, because of safety, convenient operation, and satisfactory short-term effectiveness.

Weight bearing or non-weight bearing after surgically fixed ankle fractures, the WOW! Study: study protocol for a randomized controlled trial.

BACKGROUND: The optimal post-operative care regimen after surgically fixed Lauge Hansen supination exorotation injuries remains to be established. This study compares whether unprotected weight bearing as tolerated is superior to protected weight bearing and unprotected non-weight bearing in terms of functional outcome and safety. METHODS/DESIGN: The WOW! Study is a prospective multicenter clinical trial. Patients between 18 and 65 years of age with a Lauge Hansen supination exorotation type 2, 3 or 4 ankle fractures requiring surgical treatment are eligible for inclusion. An expert panel validates the classification and inclusion eligibility. After surgery, patients are randomized to either the 1) unprotected non-weight-bearing, 2) protected weight-bearing, or 3) unprotected weight-bearing group. The primary outcome measure is ankle-specific disability measured by the Olerud-Molander ankle score. Secondary outcomes are 1) quality of life (e.g., return to work and resumption of sport), 2) complications, 3) range of motion, 4) calf wasting, and 5) maximum pressure load after 3 months and 1 year. DISCUSSION: This trial is designed to compare the effectiveness and safety of unprotected weight bearing with two commonly used post-operative treatment regimens after internal fixation of specified, intrinsically stable but displaced ankle fractures. An expert panel has been established to evaluate every potential subject, which ensures that every patient is strictly screened according to the inclusion and exclusion criteria and that there is a clear indication for surgical fixation. TRIAL REGISTRATION: The WOW! Study is registered in the Dutch Trial Register ( NTR3727 ). Date of registration: 28-11-2012.

Autologous bone marrow mononuclear cell transplant and surgical decompression in a dog with chronic spinal cord injury.

OBJECTIVES: In dogs with deep analgesia caused by acute spinal cord injury from thoracolumbar disk herniation, autologous bone marrow mononuclear cell transplant may improve recovery. The purpose of the present study was to evaluate autologous bone marrow mononuclear cell transplant in a dog that had paraplegia and deep analgesia caused by chronic spinal cord injury. MATERIALS AND METHODS: Autologous bone marrow mononuclear cell transplant was performed in a dog having paraplegia and analgesia for 3 years that was caused by a chronic spinal cord injury secondary to Hansen type I thoracolumbar disk herniation. Functional recovery was evaluated with electrophysiologic studies and the Texas Spinal Cord Injury Scale. RESULTS: Somatosensory evoked potentials were absent before transplant but were detected after transplant. Functional improvement was noted (Texas Spinal Cord Injury Scale: before transplant, 0; after transplant, 6). No adverse events were observed. CONCLUSIONS: Autologous bone marrow mononuclear cell transplant into the subarachnoid space may be a safe and beneficial treatment for chronic spinal cord injury in dogs.

Effect of Steroid Prophylaxis on Nerve Function Impairment in Multi-bacillary Leprosy Patients on MDT-MB.

The effects of corticosteroids in varying doses and duration for the treatment of reaction and nerve function impairment (NFI) in leprosy have been studied extensively. However, an optimal dose and duration of steroid when used as a prophylactic agent for NFI is yet to be established. This study was aimed to determine whether addition of low dose steroid for the initial 8 months of multi drug therapy (MDT) can prevent further deterioration of nerve function (DON) in multibacillary leprosy patients. Sixty multibacillary leprosy patients were randomized into two groups and B consisting of 30 patients each. Group A received MDT-MB for 12 months with prednisolone 20 mg/day from the beginning of treatment for 6 months followed by tapering by 5 mg/2 weeks in 7th and 8th month. Group B received MDT-MB alone for 12 months. Nerve function assessment (NFA) using various modalities was done at the beginning (0 month), at the end of 8 months and at the completion of MDT (12 months). The proportion of patients showing DON was significantly higher in group B, while proportion of patients showing improvement was more in group A. This study thus shows all MB cases with or without NFI at registration should receive prophylactic steroid at least for 8 months. Since preventing deformities using; prophylactic steroids in leprosy is an important issue larger randomized control trials using longer duration of low dose steroid witha longer follow up period should be conducted.

Epidemiology, management, and outcome of sport-related ankle fractures in a standard UK population.

BACKGROUND: The literature on the outcome of sport-related ankle fractures has focused on operatively managed fractures, despite a large proportion being treated nonoperatively. We describe the epidemiology, management, and outcome of acute sport-related ankle fractures in a UK population. METHODS: All sport-related ankle fractures sustained during 2007 to 2008 in the Lothian Population were prospectively collected when patients attended the only adult orthopaedic service in Lothian. Fractures were classified using the Lauge Hansen and the Pott's Classification. The presence of fracture displacement was also recorded. Patients were contacted in February 2011 to ascertain their progress in return to sport. RESULTS: Ninety-six sport-related ankle fractures were recorded in 96 patients. Eighty-four fractures (88%) were followed up at a mean interval of 36 months (range, 30-42). Most common associated sports were soccer (n = 49), rugby (n = 15), running (n = 5), and ice skating (n = 3). The mean time for return to sport was 26 weeks (range, 4-104), the return rate to sport 94%, and the persisting symptom rate 42%. Fifty-two fractures (all nondisplaced) were managed nonoperatively-43 isolated lateral malleolar (30 Weber B, 13 Weber A), 2 isolated medial malleolar, 7 bimalleolar. Forty-four fractures were managed operatively-42 were displaced (2 isolated lateral malleolar, 3 isolated medial malleolar, 18 bimalleolar equivalent, 9 bimalleolar, 3 trimalleolar equivalent, 7 trimalleolar), 2 were un-displaced (2 trimalleolar). The mean times for return to sport were 20 weeks (range, 4-52) for the nonoperative cohort (NOC) and 35 weeks (range, 8-104) for the operative cohort (OC) (P < .001), the return rates to sport were 100% for NOC and 87% for OC (P < .016), and the persisting symptom rates were 17% for NOC and 71% for OC (P < .001). CONCLUSIONS: Nondisplaced ankle fractures in athletes were successfully managed with nonoperative care. They had greater return rates to sport, quicker return times, and lower persisting symptom rates but had less severe injuries. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

[Quality of life of leprosy patients' group in Vietnam].

Vietnam has achieved WHO's leprosy elimination goal at a national level, but there are a lot ofex-leprosy patients who have severe physical disabilities in the leprosy treatment centers and resettlement villages. The purpose of this study is to analyze the quality of life (QOL) of ex-leprosy patients in Vietnam. The study was conducted in two leprosy treatment centers in Vietnam. The SF-36v2 QOL survey was used to evaluate the leprosy patients' health related conditions, and as a comparison group, SF-36v2 QOL survey was provided to a random group from the general population to measure the general groups' health related conditions. For those participants aged from 10 to 29 years old, the patients' group scored lower than the general group in each of the following categories; Role physical, Bodily pain, General health perceptions, Vitality, Social functioning, Role emotional. On the other hand, middle aged and elderly participants were found to show no significant difference between the patients' group and the general group. In comparing the two leprosy treatment centers, the score of Role physical and Role emotional were significantly higher in the leprosy treatment center where vocational training programs for leprosy patients are offered. From these results, the use of vocational training program is one of the effective methods for improving the QOL of the patients' group.

Factors affecting functional outcome of opponens replacement in median nerve paralysis in leprosy.

In this study, the factors affecting functional outcomes of opponens replacement in median nerve paralysis in leprosy, were investigated. Fifty six patients who underwent opponens transfer between 1995 and 2001 were included in the study. The average duration of follow up is 7.3 years with a range of 4-10 years. Functional assessments were done through assessment of grip strength, pinch strengths and fine manipulation and the results were interpreted using Sundararaj (1984) criteria. 76.6% had excellent or good results, 13.3% fair and 10.1% poor results. Pinch strength, grip strength and fine manipulation showed improvement after surgery. Logistic regression analysis showed that duration of paralysis had a significant independent effect on the outcome.

A method used to access the functional outcome of tibial posterior tendon transfer for foot drop in leprosy.

OBJECTIVES: The aim of this study was to access the postoperative functional results of posterior tibial tendon transfer for foot drop as a consequence of nerve palsy in leprosy. MATERIAL AND METHODS: Thirteen patients (9 males and 4 females) with ages ranging from 9 to 69 years were submitted to posterior tibial tendon transfer by the circumtibial route to correct foot drop in leprosy. The length of postoperative follow-up ranged from 1 to 5 years. The Stanmore system was used as a method for evaluating the functional results of postoperative posterior tibial tendon transfer. This system is made up of 7 different categories and the total score is 100. RESULTS: According to the Stanmore system, the results were poor in 1 patient (7.6%), moderate in 2 feet (15.3%), good in 5 feet (38.4%), and excellent in 5 feet (38.4%). All the patients were satisfied with the final outcome. CONCLUSION: The posterior tibial tendon transfer for foot drop in leprosy was efficient in restoring normal function of the foot and gait without changing foot posture. In the absence of a standardized method for assessing the results of posterior tibial tendon transfer, the Stanmore system seems to be a good tool for an objective evaluation.

A radiographic classification of massive rotator cuff tear arthritis.

BACKGROUND: In 1990, Hamada et al. radiographically classified massive rotator cuff tears into five grades. Walch et al. subsequently subdivided Grade 4 to reflect the presence/absence of subacromial arthritis and emphasize glenohumeral arthritis as a characteristic of Grade 4. QUESTIONS/PURPOSES: We therefore determined (1) whether patient characteristics and MRI findings differed between the grades at initial examination and final followup; (2) which factors affected progression to a higher grade; (3) whether the retear rate of repaired tendons differed among the grades; and (4) whether the radiographic grades at final followup differed from those at initial examination among patients treated operatively. PATIENTS AND METHODS: We retrospectively reviewed 75 patients with massive rotator cuff tears. Thirty-four patients were treated nonoperatively and 41 operatively. RESULTS: Patients with Grade 3, 4, or 5 tears had a higher incidence of fatty muscle degeneration of the subscapularis muscle than patients with Grade 1 or 2 tears. In 26 patients with Grade 1 or 2 tears at initial examination, duration of followup was longer in patients who remained at Grade 1 or 2 than in those who progressed to Grade 3, 4, or 5 at final followup. The retear rate of repaired supraspinatus tendon was more frequent in Grade 2 than Grade 1 tears. In operated cases, radiographic grades at final followup did not develop to Grades 3 to 5. CONCLUSIONS: We believe cuff repair should be performed before acromiohumeral interval narrowing. Our observations are consistent with the temporal concepts of massive cuff tear pathomechanics proposed by Burkhart and Hansen et al. LEVEL OF EVIDENCE: Level III, Therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Surgical versus nonsurgical treatment of the SE4-equivalent ankle fracture: a retrospective functional outcome study.

Treatment of Lauge-Hansen supination-eversion (SE)4-equivalent ankle fractures is controversial. This retrospective study conducted at a level-I trauma center compared the clinical outcome of nonsurgical vs open management of these fractures. One thousand eight ankle fractures treated between 1998 and 2003 were reviewed. Forty-three patients who met the criteria for a SE4-equivalent ankle fracture were identified. Average patient age of 23 men and 20 women was 42 years (range, 18-84 years). Olerud Molander ankle scores were recorded. Medical records and radiographs of all patients were reviewed. Average follow-up was 20 months.Twenty-six patients were treated nonsurgically, with an average ankle score of 84 ± 4. Seventeen patients treated surgically had an average ankle score of 63 ± 5. The difference is statistically significant (unpaired t test, P=.0035). There was no difference between open vs closed treatment in maintaining a reduction. To investigate the reason for poor results in the surgical group, we sought an association between functional ankle score and common covariables and found that age and preoperative radiographic grading were important variables for ankle score. Patients younger than 30 years had an average ankle score of 85, whereas those older than 50 years had an average score of 61 (P<.001). Type 1 fractures (medial clear space >5 mm in stress view only) had an average ankle score of 89, type 2 (medial clear space >5 mm but <10 mm) an average score of 76, and type 3 (medial clear space >10 mm or presented with fracture dislocation and/or syndesmosis injury) an average score of 61. Our data support that type 1 and 2 fractures can effectively be treated nonsurgically.

Evaluation of activity limitation and social participation, and the effects of reconstructive surgery in people with disability due to leprosy: a prospective cohort study.

PURPOSE: To assess how activity limitation and social participation of individuals with leprosy-related disability change over time, and to quantify the effect of reconstructive surgery. METHOD: Individuals with disability due to leprosy who accepted invitations for assessment at a leprosy clinic between March and July 2007 were interviewed using the SALSA Scale (measuring activity limitation) and the Participation Scale (assessing social participation). All participants were offered reconstructive surgery. Follow-up interviews were done 1 year after the first interview or 1 year after surgery. The main outcomes were changes in SALSA score and Participation score. We used analysis of variance to identify the effects of independent factors on mean SALSA and Participation scores. RESULTS: We interviewed 222 participants, 15 of whom took up the offer of surgery and 207 who did not. Comparison of SALSA Scale scores at baseline and 1 year revealed that activity limitation did not significantly change over time in individuals who declined surgery; however, participants who had surgery showed a significant improvement at 1 year (p < 0.001). Social participation improved over time in both groups, but the difference was significant only in the non-surgery group (p < 0.001). CONCLUSIONS: The findings suggest that reconstructive surgery has beneficial effects on functioning. Evaluation of the need for, and effect of, surgery in larger studies is recommended.

Functional connectivity metrics during stroke recovery.

We explore functional connectivity in nine subjects measured with 1.5T fMRI-BOLD in a longitudinal study of recovery from unilateral stroke affecting the motor area (Small et al., 2002). We found that several measures of complexity of covariance matrices show strong correlations with behavioral measures of recovery. In Schmah et al. (2010), we applied Linear and Quadratic Discriminants (LD and QD) computed on a principal components (PC) subspace to classify the fMRI volumes into "early" and "late" sessions. We demonstrated excellent classification accuracy with QD but not LD, indicating that potentially important differences in functional connectivity exist between the early and late sessions. Motivated by Mclntosh et al. (2008), who showed that EEG brain-signal variability and behavioral performance both increased with age during development, we investigated complexity of the covariance matrix for this longitudinal stroke recovery data set. We used three complexity measures: the sphericity index described by Abdi (2010); "unsupervised dimensionality", which is the number of PCs that minimizes unsupervised generalization error of a covariance matrix (Hansen et al., 1999); and "QD dimensionality", which is the number of PCs that minimizes the classification accuracy of QD. Although these approaches measure different kinds of complexity, all showed strong correlations with one or more behavioral tests: nine-hole peg test, hand grip test and pinch test. We could not demonstrate that either sphericity or unsupervised dimensionality were significantly different for the "early" and "late" sessions using a paired Wilcoxon test. However, the amount of relative behavioral improvement was correlated with sphericity of the overall covariance matrix (pooled across all sessions), as well as with the divergence of the eigenspectra between the "early" and "late" covariance matrices. Complexity measures that use the number of PCs (which optimize QD classification or unsupervised generalization) were correlated with the behavioral performance of the final session, but not with the relative improvement. These are suggestive, but limited, results given the sample size, restricted behavioral measurements and older 1.5T BOLD data sets. Nevertheless, they indicate one potentially fruitful direction for future data-driven fMRI studies of stroke recovery in larger, better-characterized longitudinal stroke data sets recorded at higher field strength. Finally, we produced sensitivity maps (Kjems et al., 2002) corresponding to both linear and quadratic discriminants for the "early" vs. "late" classification. These maps measure the influence of each voxel on the class assignments for a given classifier. Differences between the scaled sensitivity maps for the linear and quadratic discriminants indicate brain regions involved in changes in functional connectivity. These regions are highly variable across subjects, but include the cerebellum and the motor area contralateral to the lesion.

Early active motion versus immobilization after tendon transfer for foot drop deformity: a randomized clinical trial.

BACKGROUND: Immobilization after tendon transfers has been the conventional postoperative management. Several recent studies suggest early mobilization does not increase tendon pullout. QUESTIONS/PURPOSES: To confirm those studies we determined whether when compared with immobilization early active mobilization after a tendon transfer for foot-drop correction would (1) have a similar low rate of tendon insertion pullout, (2) reduce rehabilitation time, and (3) result in similar functional outcomes (active ankle dorsiflexion, plantar flexion, ROM, walking ability, Stanmore score, and resolution of functional problems. METHODS: We randomized 24 patients with surgically corrected foot-drop deformities to postoperative treatment with early mobilization with active motion at 5 days (n = 13) or 4 weeks of immobilization with active motion at 29 days (n = 11). In both groups, the tibialis posterior tendon was transferred to the extensor hallucis longus and extensors digitorum communis for foot-drop correction. Rehabilitation time was defined as the time from surgery until discharge from rehabilitation with independent walking. The minimum followup was 16 months (mean, 19 months; range, 16-38 months) in both groups. RESULTS: We observed no case of tendon pullout in either group. Rehabilitation time in the mobilized group was reduced by an average of 15 days. The various functional outcomes were similar in the two groups. CONCLUSION: In patients with Hansen's disease, an early active mobilization protocol for foot-drop correction has no added risk of tendon pullout and provides similar functional outcomes compared with immobilization. Early mobilization had the advantage of earlier restoration of independent walking. LEVEL OF EVIDENCE: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

A randomized clinical trial comparing immediate active motion with immobilization after tendon transfer for claw deformity.

PURPOSE: Immobilization after tendon transfers has been the conventional postoperative management. A recent study indicated beneficial effects of an immediate active motion protocol (IAMP) after tendon transfer for claw deformity correction compared with effects in a historical cohort. In this study, we further tested this hypothesis in a randomized clinical trial comparing the effectiveness of the IAMP with that of conventional immobilization. METHODS: Fifty supple claw hand deformities were randomized postoperatively into 2 equal groups for IAMP and immobilization. Therapy began on the second postoperative day for the IAMP group and on the twenty-second postoperative day for the immobilization group. The primary outcome measures were deformity correction, active range of motion of digits, tendon transfer insertion pullout, and time until discharge from rehabilitation. Secondary outcome measures were swelling, pain, hand strength, and dexterity. Both groups were compared at discharge from rehabilitation and at the last clinical follow-up (at least 1 year postoperatively). RESULTS: Assessments were available for all 50 patients at discharge and for 23 patients in each group at follow-up. The average follow-up was 18 months for the IAMP group and 17 months for the immobilization group. Deformity correction, range of motion, swelling, dexterity, and hand strength were similar for both groups at discharge and a follow-up. There was no evidence of tendon insertion pullout in any patient of either group. Relief of pain was achieved significantly earlier with IAMP. Morbidity was reduced by, on average, 22 days with IAMP. CONCLUSIONS: We found that the immediate active motion protocol is safe and has similar outcomes compared with those of immobilization, with the added advantage of earlier pain relief and quicker restoration of hand function. Immediate motion after tendon transfer can significantly reduce morbidity and speed up the rehabilitation of paralytic limbs, and it may save expense for the patients.

[Post-treatment of Leprosy in Ceará: activity and functional limitation, safety awareness and social participation]. / Pós-alta em Hanseníase no Ceará: limitação da atividade funcional, consciência de risco e participação social.

To characterize the functional limitation, activity limitation, risk conscience, and the social participation in people reached by hansen's disease in the post-MDT period. Cross-sectional, descriptive study, accomplished in 2006. Sixty-nine residents in Sobral that had discharge from MDT between 2003-2005 participated. The subjects were interviewed: demographic evaluation, dermato-neurological exams, evaluation of functional limitation-activity-risk conscience and the restriction in social participation. Twenty (28.9%) presented SALSA scores 19 and 20 and EHF score zero. The largest EHF score was reached by two participants, with scores 25 and 28 in the SALSA scale. In the participation scale 37 (53.6%) didn't present restriction and had EHF scores zero. Two (2.9%) with EHF score zero had mild restriction, and 1 (1.5%) severe restriction. This study reaffirms the potentiality of these tools for integral care of people reached.

A rational approach to ankle fractures.

Ankle fractures involve a spectrum of injury patterns from simple to complex, such that these injuries are not always "just an ankle fracture." By combining the injury mechanism and the radiographic findings, the surgeon can apply the Lauge-Hansen classification in taking a rational approach to the management of these fractures. Syndesmotic instability and atypical patterns are becoming increasingly recognized, in part through the judicious use of CT scans. The goal of surgical stabilization includes atraumatic soft tissue management, rigid internal fixation, and early range of motion exercises in maximizing return of function.