Clinical effects of equine-assisted therapeutic exercises in static and dynamic balance of children with cerebral palsy.

OBJECTIVE: To evaluate the efficacy of equine-assisted therapy for the static and dynamic balance in the rehabilitation of children and adolescents with cerebral palsy maintaining obtained improvement 8-weeks after the end of the intervention. METHOD: The study lasted 28 weeks, of which the intervention lasted 12 weeks. Measurements were taken before, in the middle, after the end of the intervention and follow-up after 12 weeks. Paediatric Balance Scale and dynamic plate were used to evaluate the balance. Wechsler Intelligence Scale for Children (3rd edition) was used to assess mental capacity, and the Gross Motor Function Classification System for the assessment of functional capacity for the participants. Exercises on the horseback were individualised for every participant. RESULTS: The study comprised 27 participants with cerebral palsy. Statistically significant improvements were found for the Paediatric Balance Scale (p<0.001) and the mean dynamic plate pressure for both feet (p<0.05). The Paediatric Balance Scale results remained in the follow-up and were found clinically significant. CONCLUSIONS: The results suggest that this type of approach in rehabilitation can be beneficial with clinical significance for improving the motor dysfunctions and quality of life in cerebral palsy.

The effect of disability and gender mediated by depression on health-related quality of life of Greek stroke patients in the subacute rehabilitation phase: a prospective cohort study.

Background: Stroke has been associated with compromised patient outcomes, such as a decreased quality of life. We aimed in the present study to evaluate the health-related quality of life (HRQοL) of hospitalized Greek stroke patients during the sub-acute rehabilitation period and assess the effect of demographic and clinical characteristics mediated by depressive symptom severity on HRQοL. Methods: In a prospective study, a cohort of adult patients hospitalized in the sub-acute phase of their first stroke episode were assessed in the Rehabilitation Clinic of the University Hospital of Ioannina in Greece. Patients' functional status, depressive symptom severity, and HRQοL were evaluated twice, using the Patient Health Questionnaire 9 (PHQ-9), the Barthel Index (BI), and the World Health Organization Quality of Life Brief Version (WHOQOL-BREF), respectively. All patients received physical, occupational, and speech therapy during their rehabilitation. Results: Fifty consecutive adult stroke patients were enrolled. We detected a statistically significant (p <0.001) improvement in WHOQOL-BREF, especially in the "psychological health" and "environment" domains, BI, and PHQ-9 scores, between the initial and follow-up assessments. Mediation analysis revealed that baseline disability had both a significant direct (estimate =0.014, p <0.001) and indirect (estimate =0.010, p <0.001, PHQ-9 as mediator) effect on the total HRQoL score. Gender and stroke localization had significant direct effects on HRQoL total (estimate =-0.432, p =0.009, and estimate =0.395, p =0.031, respectively), while PHQ-9 mediation was insignificant. Antidepressant medications and stroke type did not play a substantial role in HRQoL. Conclusion: By the end of the subacute rehabilitation phase, patients' HRQoL, functionality and depression severity improved. Additionally, baseline functionality, stroke localization, and gender directly or indirectly (mediated by initial depression severity) affected HRQoL, with male patients and patients with stroke non-involving the frontal lobe/basal ganglia showing a better HRQoL by the end of rehabilitation. HIPPOKRATIA 2023, 27 (1):12-17.

Association of malnutrition with surgical site infection following spinal surgery: systematic review and meta-analysis.

BACKGROUND: Surgical site infection (SSI) following spinal surgery is a frequent clinical problem with significant clinical and socio-economic consequences. Malnutrition has been linked with SSI in various other surgical procedures. AIM: To investigate whether malnutrition is a risk factor for SSI following spinal surgery. METHODS: Two electronic databases (PUBMED and SCOPUS) and the Cochrane Library were searched systematically from inception to May 2019. Cohort and case-control studies assessing malnutrition as a risk factor for SSI in patients undergoing spinal procedures were considered eligible. Μalnutrition was defined according to laboratory measurements or by relevant International Classification of Diseases-9 codes. SSI was the outcome of interest. Two reviewers independently abstracted study data and assessed the risk of bias for each study. Pooled effect estimates were calculated using random effects models. FINDINGS: In total, 22 studies (20 retrospective cohort and two case-control) with over 175,000 participants (of whom 2.14% developed postoperative SSI) were analysed. SSIs were more likely to develop in malnourished patients [odds ratio (OR) 2.31, 95% confidence interval (CI) 1.75-3.05]. While pre-operative malnutrition was significantly associated with SSI in patients undergoing thoracolumbar spinal and sacral surgery, no significant difference was seen in patients undergoing cervical spinal surgery. In subgroup analyses, similar results were observed for both hospital-based (OR 3.16, 95% CI 1.84-5.43) and population-based (OR 2.00, 95% CI 1.63-2.46) studies. CONCLUSIONS: Malnutrition is associated with increased risk of developing SSI after spinal surgery. Further high-quality research is warranted to investigate whether improvement of pre-operative nutritional status can decrease SSI rates.

Rehabilitation of the multiple injured patient with spinal cord injury: A systematic review of the literature.

INTRODUCTION: Patients with multiple injuries including spinal cord injury (SCI) have low survivability. Little is known for the effect of SCI in their rehabilitation process. PURPOSE: To define differences in characteristics and outcomes during the rehabilitation of multiple injured patients with SCI compared to other polytrauma patients. MATERIALS AND METHODS: Electronic libraries provided 425 relevant articles. Applying the criteria, 6 articles were eligible for inclusion in this review. RESULTS: The extracted data show that multiple injured patients with SCI have an increased length of stay (LOS) in rehabilitation. Initial functional levels, as also one- and two-years follow-up are also decreased. Similar results were found comparing SCI patients with or without multiple injuries: SCI patients with multiple injuries have an increased LOS and decreased functional levels compared with SCI patients. Finally, there was nota relevance between the circumstances of the injuries, like acts of terror, and the expected rehabilitation outcome. CONCLUSION: Due to the rarity of eligible articles and the lack of homogenous accessing tools, a meta-analysis was not possible. There is a lack of a universal evaluation strategy or tool, for the severity of the multiple injured patients aiming at the rehabilitation outcome prognosis. Multiple-injured patients with SCI have longer rehabilitation LOS and functional outcomes compared to other polytrauma patients. Prospective studies are needed for evaluation of the differences according to the severity and the complexity of the injuries and the rehabilitation outcome depending on different rehabilitation methods and strategies.

Salvage of an infected titanium mesh in a large incisional ventral hernia using medicinal honey and vacuum-assisted closure: a case report and literature review.

The overall reported percentage of mesh infections is 1.3%. Infections after incisional ventral hernia repair depend on many factors. Salvaging an infected mesh should be the priority, because serious complications are reported following mesh removal. In this case report, a methicillin-resistant Staphylococcus aureus (MRSA)-infected titanium mesh was salvaged by a novel technique, not requiring removal. The combination of vacuum-assisted closure (VAC™ therapy) of the wound and medical honey (L-Mesitran™) proved to be successful in leaving the mesh in situ. We report the successful management of this infected titanium mesh and review the literature regarding the possible pathogenetic mechanisms and treatment options.

Ipsilateral atrophy of paraspinal and psoas muscle in unilateral back pain patients with monosegmental degenerative disc disease.

OBJECTIVES: The aim of this study was to assess the cross-sectional area (CSA) of both paraspinal and psoas muscles in patients with unilateral back pain using MRI and to correlate it with outcome measures. METHODS: 40 patients, all with informed consent, with a minimum of 3 months of unilateral back pain with or without sciatica and one-level disc disease on MRI of the lumbosacral spine were included. Patients were evaluated with self-report measures regarding pain (visual analogue score) and disability (Oswestry disability index). The CSA of multifidus, erector spinae, quadratus lumborum and psoas was measured at the disc level of pathology and the two adjacent disc levels, bilaterally. Comparison of CSAs of muscles between the affected vs symptomless side was carried out with Student's t-test and correlations were conducted with Spearman's test. RESULTS: The maximum relative muscle atrophy (% decrease in CSA on symptomatic side) independent of the level was 13.1% for multifidus, 21.8% for erector spinae, 24.8% for quadratus lumborum and 17.1% for psoas. There was significant difference (p<0.05) between sides (symptomatic and asymptomatic) in CSA of multifidus, erector spinae, quadratus lumborum and psoas. However, no statistically significant correlation was found between the duration of symptoms (average 15.5 months), patient's pain (average VAS 5.3) or disability (average ODI 25.2) and the relative muscle atrophy. CONCLUSION: In patients with long-standing unilateral back pain due to monosegmental degenerative disc disease, selective multifidus, erector spinae, quadratus lumborum and psoas atrophy develops on the symptomatic side. Radiologists and clinicians should evaluate spinal muscle atrophy of patients with persistent unilateral back pain.

Length of stay and medical stability for spinal cord-injured patients on admission to an inpatient rehabilitation hospital: a comparison between a model SCI trauma center and non-SCI trauma center.

STUDY DESIGN: Retrospective database review. OBJECTIVE: To compare lengths of stay (LOS), pressure ulcers and readmissions to the acute care hospital of patients admitted to the inpatient rehabilitation facility (IRF) from a model spinal cord injury (SCI) trauma center or from a non-SCI acute hospital. BACKGROUND: Only sparse data exist comparing the status of patients admitted to IRF from a model SCI trauma center or from a non-SCI acute hospital. METHODS: Acute care, IRF and total LOS were compared between patients transferred to IRF from the SCI center (n=78) and from non-SCI centers (n=131). The percentages of pressure ulcers on admission to IRF and transfer back to acute care were also compared. RESULTS: Patients admitted to IRF from the SCI trauma center (SCI TC) had significantly shorter (P=0.01) acute care LOS and total LOS compared with patients admitted from non-SCI TCs. By neurological category, acute-care LOS was less for all groups admitted from the SCI center, but statistically significant only for tetraplegia. There was no significant difference in the incidence of readmissions to acute care from IRF. More patients from non-SCI centers (34%) than SCI centers (12%) had pressure ulcers (P<0.001). CONCLUSION: Acute care in organized SCI TCs before transfer to IRF can significantly lower acute-care LOS or total LOS and incidence of pressure ulcers compared with non-SCI TCs. Patients admitted to IRF from SCI TCs are no more likely to be sent back to an acute hospital than those from non-SCI TCs.

A systematic review of the evidence supporting a role for vasopressor support in acute SCI.

STUDY DESIGN: A systematic review of clinical and preclinical literature. OBJECTIVE: To critically evaluate the evidence supporting a role for vasopressor support in the management of acute spinal cord injury and to provide updated recommendations regarding the appropriate clinical application of this therapeutic modality. BACKGROUND: Only few clinical studies exist examining the role of arterial pressure and vasopressors in the context of spinal cord trauma. METHODS: Medical literature was searched from the earlier available date to July 2009 and 32 articles (animal and human literature) answering the following four questions were studied: what patient groups benefit from vasopressor support, which is the optimal hypertensive drug regimen, which is the optimal duration of the treatment and which is the optimal arterial blood pressure. Outcome measures used were the incidence of patients needing vasopressors, the increase of arterial blood pressure and neurologic improvement. RESULTS: Patients with complete cervical cord injuries required vasopressors more frequently than either incomplete injuries or thoracic/lumbar cord injuries (P<0.001). There was no statistical difference in neurologic improvement between patients on vasopressor support with a mean arterial pressure (MAP) of less than 85 mm Hg and those with MAP less than 90 mm Hg. Duration of treatment is often recommended between 5 and 7 days although this is not supported by high-level evidence and no single vasopressor appeared superior over the variety used in clinical treatment. CONCLUSION: There is currently no gold standard on vasopressor support. Based on non-randomized human studies, complete cervical cord injuries require vasopressors more frequently than other spinal cord injuries.

Thromboprophylaxis in patients with acute spinal injuries: an evidence-based analysis.

BACKGROUND: The increased risk for venous thromboembolic events following spinal trauma is well established. The purpose of the present study was to examine the literature in order to determine the optimum thromboprophylaxis regimen for patients with acute spinal injuries with or without spinal cord injury. METHODS: EMBASE, MEDLINE, and Cochrane databases were searched from the earliest available date to April 2008 for clinical trials comparing different methods of thromboprophylaxis in adult patients following acute spinal injuries (with or without spinal cord injury). Outcome measures included the prevalences of deep-vein thrombosis and pulmonary embolism and treatment-related adverse events. RESULTS: The search yielded 489 studies, but only twenty-one of them fulfilled the inclusion criteria. The prevalence of deep-vein thrombosis was significantly lower in patients without spinal cord injury as compared with patients with spinal cord injury (odds ratio = 6.0; 95% confidence interval = 2.9 to 12.7). Patients with an acute spinal cord injury who were receiving oral anticoagulants had significantly fewer episodes of pulmonary embolism (odds ratio = 0.1; 95% confidence interval = 0.01 to 0.63) than those who were not receiving oral anticoagulants (either untreated controls or patients managed with low-molecular-weight heparin). The start of thromboprophylaxis within the first two weeks after the injury resulted in significantly fewer deep-vein-thrombosis events than delayed initiation did (odds ratio = 0.2; 95% confidence interval = 0.1 to 0.4). With regard to heparin-based pharmacoprophylaxis in patients with spinal trauma, low-molecular-weight heparin significantly reduced the rates of deep-vein thrombosis and bleeding episodes in comparison with the findings in patients who received unfractionated heparin, with odds ratios of 2.6 (95% confidence interval = 1.2 to 5.6) and 7.5 (95% confidence interval = 1.0 to 58.4) for deep-vein thrombosis and bleeding, respectively. CONCLUSIONS: The prevalence of deep-vein thrombosis following a spine injury is higher among patients who have a spinal cord injury than among those who do not have a spinal cord injury. Therefore, thromboprophylaxis in these patients should start as early as possible once it is deemed safe in terms of potential bleeding complications. Within this population, low-molecular-weight heparin is more effective for the prevention of deep-vein thrombosis, with fewer bleeding complications, than unfractionated heparin is. The use of vitamin K antagonists appeared to be effective for the prevention of pulmonary embolism.

Supracondylar femoral fractures in elderly patients treated with the dynamic condylar screw and the retrograde intramedullary nail: a comparative study of the two methods.

INTRODUCTION: The objective of this study is to present the results of surgical management of supracondylar fractures of the femur (types A and C according to the AO/ASIF classification) in elderly patients with the use of two different methods of fixation: the mini open dynamic condylar screw fixation (DCS) and the closed retrograde intramedullary nailing (RIN). MATERIALS AND METHODS: Eighty patients with supracondylar fractures of the femur were treated from January 1994 to June 2000 and 72 of them followed up completely. There were 25 (34%) men and 47 (65%) women with a median age of 73.2 years (range 60-88 years). In patients with the same type of fracture, the chosen method was random, one after the other (alternately). RIN was used in 35 patients, and DCS was used in 37. The mean operative time for the DCS fixation group was 145 min (range 115-180 min), whereas for the RIN group it was 92 min (range 76-110 min) (p<0.001) with an average estimated blood loss of 310 cc (range 120-450 cc) and 118 cc (range 90-165 cc), respectively (p<0.001). The mean follow-up was 28 months (range 18-42 months). RESULTS: According to the criteria set by Schatzker and Lambert, excellent results were recorded in 18 (51%), good in 11 (31%), moderate in 3 (9%), poor in 3 (9%) patients with RIN and excellent in 19 (51%), good in 11 (30%), moderate in 4 (11%) and poor in 3 (8%) patients with DCS (p>0.05). The complications that occurred in the RIN group were 2 (6%) stiffness of the knee (mean flexion 80 degrees), 2 (6%) non-unions, 2 (6%) varus deformity and in the DCS group 2 (5%) haematomas, 4 (11%) stiffness of the knee (mean flexion 73 degrees) and 2 (5%) non-unions. CONCLUSION: Although the two methods appear to have the same percentage of excellent results and same time to bony union, RIN is preferable to DCS in terms of less blood loss and shorter operating time.

The appearance of kissing contusion in the acutely injured knee in the athletes.

BACKGROUND: Bone contusions are often identified at magnetic resonance imaging (MRI) in the acutely injured knee. Contusions of both surfaces of the joint are known as kissing contusions. OBJECTIVE: To determine the frequency, type, and distribution of kissing contusions occurring in association with injuries of the knee joint. METHODS: 255 MRI examinations in athletes with acutely injured knees (197 men; 58 women; mean age 24.2 years) were reviewed by two independent examiners; 219 MRIs were done within the first month after the injury and 36 within two to four months. None of the knees had been injured before. No fractures were present on x ray. RESULTS: Bone contusions were diagnosed in 71 cases (27.8%); 55 (22.5%) were identified as single contusions and 16 (6.3%) as kissing contusions. Eight of the kissing contusions were associated with anterior cruciate ligament tears, three with menisceal tears, four were isolated lesions, and one was delayed, following a menisceal tear. The 32 bone contusions (16 kissing contusions) were located as follows: lateral femoral condyle (n = 14; 8 type I, 6 type II); lateral tibial condyle (n = 9; 3 type I, 1 type II, 5 type III); medial tibial condyle (n = 7; 2 type I, 5 type III); medial femoral condyle (n = 2; both type I). The associated injuries were confirmed by arthroscopy in 12/16 patients. CONCLUSIONS: Kissing contusion is a significant injury often associated with ligamentous or menisceal injuries. Type I lesions are most common on the lateral femoral condyle and type III on the lateral tibial condyle.

A combined proximal and distal dislocation of two adjacent metatarsals: double floating metatarsal bones (second-third).

A rare foot injury consisting of an irreducible, closed combined distal and proximal articulation dislocation of two adjacent metatarsals (second and third), called a "double floating metatarsal," was encountered in a 29-year-old man. The anatomy, mechanism of injury, and sequence of the surgical procedure are presented and discussed.

Idiopathic scoliosis. Segmental fusion with transpedicular screws.

The purpose of this study is to evaluate whether the surgical correction of the scoliotic curve with the use of segmental pedicle screw fixation system is effective. We studied 20 patients (19 girls, 1 boy) with a mean age of 14,6 years (range from 13 to 22). The spinal deformities were evaluated by Cobb method with anteroposterior and lateral bending radiographs. There were 13 right thoracic curves and 7 left thoracolumbar curves. The width of the pedicles was estimated in all patients by computerized tomography of the thoracic and lumbar spine. Posterior instrumentation (Moss-Miami transpedicular system) was used and additional thoracoplasty was performed in 2 patients. The transpedicular screws were placed between T2 and L5. Intraoperatively the image intensification was indispensable and the wake-up test was always conducted. All the patients were assessed both clinically and radiographically at 3,6,9,12 months and annually until now. The average follow-up was two years. There was an average correction of 73% of the primary curve (pre-op standing average 59 degrees (range from 42 degrees to 87 degrees), lateral bending average 33 degrees (range from 10 degrees to 75 degrees), post-op average 13 degrees (range from 6 to 30 degrees), at last examination average 14 degrees (range from 6 degrees to 33 degrees). Infection and neurological complications were not noted. No major complications were observed. Exact evaluation of the pedicles by CT scan is an essential prerequisite for transpedicular screw insertion. The correction of idiopathic curves with the use of segmental pedicle screw fixation system is a very effective method(correction > 70%) It seems that control of the three columns of the spine by the transpedicular screws offers sufficient apical translation and coronal realignment.

Surgical management of a congenital kyphotic deformity in an adolescent.

This is a case of an adolescent with kyphoscoliosis due to congenital partially segmented vertebrae T12, L1, L2 who was treated operatively by a back-front-back, one stage operation. A 16 year old patient neurologically intact with a rounded gibbous in the lower thoracic region and a mild scoliotic element had no other congenital anomaly. His kyphotic deformity was 85 degrees measured with the Cobb method. Preoperatively, a CT and MRI scan of the spine was performed and a three-level anterolateral failure of segmentation in the thoracic spine was diagnosed without spinal dysraphism. The operation lasted 8 hours and the Moss-Miami anterior and posterior fixation systems were used for fusion from T10 to T4. It included initially posterior approach for transpendicular screw insertion, wedge resection of the posterior elemens followed by anterior approach (thoracotomy), osteotomy of the defected vertebrae, anterior correction and fusion T11 to L1 and final correction with rod placement posteriorly. The wake-up test was performed twice. The follow-up was 3 years. The postoperative correction of the kyphosis was 45% (42 degrees) and there was practically no loss of correction in the last follow-up. No complications were observed. Detailed preoperative assessment of the patients with congenital deformities is essential in order to establish the correct diagnosis and choose the proper treatment. Substantial kyphotic deformities require combined antero-posterior procedures.

Dislocation of bipolar hemiarthroplasty following breakage of the polyethylene ring.

Dislocation after bipolar hemiarthroplasty is rare. In classical dislocations of bipolar prosthesis, the prosthetic femoral head escapes from the natural acetabular cavity. Two cases of a bipolar hip prosthesis are presented in which the dislocation occurred between the cup and the metallic ball head 4 and 12 months postoperatively. The reason for the dislocation was fracturing of the edge of the polyethylene ring - either due to impingement at the full flexion position of the hip or to dislocating forces in extreme positions of the metallic ball head. To avoid this complication we recommend installation of the notch of the polyethylene ring be at the peripheral half of the acetabular cup.