Randomized controlled trial of pharmacological replacement of melatonin for sleep disruption in individuals with tetraplegia

Objective

To determine the effectiveness of a melatonin agonist for treating sleep disturbances in individuals with tetraplegia.

Design

Placebo-controlled, double-blind, crossover, randomized control trial.

Setting

At home.

Participants

Eight individuals with tetraplegia, having an absence of endogenous melatonin production and the presence of a sleep disorder.

Interventions

Three weeks of 8 mg of ramelteon (melatonin agonist) and 3 weeks of placebo (crossover, randomized order) with 2 weeks of baseline prior to and 2 weeks of washout between active conditions.

Outcome

Change in objective and subjective sleep.

Measures

Wrist actigraphy, post-sleep questionnaire, Stanford sleepiness scale, SF-36.

Results

We observed no consistent changes in either subjective or objective measures of sleep, including subjective sleep latency (P = 0.55, Friedman test), number of awakenings (P = 0.17, Friedman test), subjective total sleep time (P = 0.45, Friedman test), subjective morning alertness (P = 0.35, Friedman test), objective wake after sleep onset (P = 0.70, Friedman test), or objective sleep efficiency (P = 0.78, Friedman test). There were significant increases in both objective total sleep time (P < 0.05, Friedman test), subjective time in bed (P < 0.05, Friedman test), and subjective sleep quality (P < 0.05, Friedman test), although these occurred in both arms. There were no significant changes in any of the nine SF-36 subscale scores (Friedman test, Ps >Bonferroni adjusted α of 0.005).

Conclusion

In this pilot study, we were unable to show effectiveness of pharmacological replacement of melatonin for the treatment of self-reported sleep problems in individuals with tetraplegia.

Trial Registration

ClinicalTrials.gov # {"type":"clinical-trial","attrs":{"text":"NCT00507546","term_id":"NCT00507546"}}NCT00507546.     

Underestimation of Bone Loss of the Spine With Posterior-Anterior Dual-Energy X-Ray Absorptiometry in Patients With Spinal Cord Injury

Background:

Bone mineral density (BMD) of the lumbar spine (L-spine) has been reported to be normal by routine posterior-anterior (PA) bone density imaging in patients with chronic spinal cord injury (SCI).

Objective:

To determine BMD of the L-spine by PA and lateral (LAT) dual-energy radiographic absorptiometry (DXA) in patients with chronic SCI.

Design:

Prospective study.

Setting:

Veterans Affairs Medical Center and a private rehabilitation facility.

Methods:

Measurements of the PA and LAT L-spine and hip were performed in 15 patients with SCI: 9 with tetraplegia and 6 with paraplegia. The DXA (GE Lunar Advance DXA) images were obtained using standard software. Results are reported as mean ± SD.

Results:

The mean age was 35 ± 15 years (range  =  20–62 years), and the duration of injury was 57 ± 74 months (range  =  3–240 months). T- and Z-scores were lower for the LAT L-spine than those for PA L-spine (T-scores L2: −0.7 ± 1.2 vs 0.0 ± 1.4, P < 0.01; L3: −0.9 ± 1.6 vs 0.3 ± 1.3, P < 0.002; L2-L3: −0.8 ± 1.3 vs 0.2 ± 1.3, P < 0.001; Z-scores L2: −0.3 ± 1.1 vs 0.2 ± 1.2, P < 0.05; L3: −0.6 ± 1.3 vs 0.5 ± 1.3, P < 0.01; L2-L3: −0.4 ± 1.1 vs 0.4 ± 1.2, P < 0.005). The T- and Z-scores for the total hip (−1.1 ± 1.0 and −1.0 ± 1.0, respectively) and L2-L3 LAT L-spine demonstrated remarkable similarity, whereas the L2-L3 PA L-spine scores were not reduced. Bone mineral density of the LAT L-spine, but not the PA L-spine, was significantly reduced with increasing duration of injury.

Conclusions:

Individuals with SCI may have bone loss of the L-spine that is evident on LAT DXA that may be misdiagnosed by PA DXA, underestimating the potential risk of fracture.     

Assessment of passive knee stiffness and viscosity in individuals with spinal cord injury using pendulum test

Objective

Stiffness and viscosity represent passive resistances to joint motion related with the structural properties of the joint tissue and of the musculotendinous complex. Both parameters can be affected in patients with spinal cord injury (SCI). The purpose of this study was to measure passive knee stiffness and viscosity in patients with SCI with paraplegia and healthy subjects using Wartenberg pendulum test.

Design

Non-experimental, cross-sectional, case–control design.

Setting

An outpatient physical therapy clinic, University of social welfare and Rehabilitation Science, Iran.

Patients

A sample of convenience sample of 30 subjects participated in the study. Subjects were categorized into two groups: individuals with paraplegic SCI (n = 15, age: 34.60 ± 9.18 years) and 15 able-bodied individuals as control group (n = 15, age: 30.66 ± 11.13 years).

Interventions

Not applicable.

Main measures

Passive pendulum test of Wartenberg was used to measure passive viscous-elastic parameters of the knee (stiffness, viscosity) in all subjects.

Results

Statistical analysis (independent t-test) revealed significant difference in the joint stiffness between healthy subjects and those with paraplegic SCI (P = 0.01). However, no significant difference was found in the viscosity between two groups (P = 0.17). Except for first peak flexion angle, all other displacement kinematic parameters exhibited no statistically significant difference between normal subjects and subjects with SCI.

Conclusions

Patients with SCI have significantly greater joint stiffness compared to able-bodied subjects.     

Lean tissue mass and energy expenditure are retained in hypogonadal men with spinal cord injury after discontinuation of testosterone replacement therapy

Objective

To determine whether favorable changes to lean tissue mass (LTM), resting energy expenditure (REE), and testosterone (T) that occurred with 12 months of physiological testosterone replacement therapy (TRT) were retained 6 months after discontinuing treatment.

Design

Prospective, open-label, controlled drug intervention trial.

Setting

Metropolitan area hospitals.

Subjects

Eugonadal (n = 11) and hypogonadal (n = 13) men with chronic spinal cord injury (SCI).

Interventions

Hypogonadal subjects received a 5 or 10 mg transdermal T patch daily for 12 months, with adjustment of the dose to normalize the serum T concentration; TRT was discontinued after 12 months (TRT-12M) and subjects were followed for an additional 6 months and re-evaluated (Post-TRT). Total body dual energy X-ray absorptiometry and blood draws were performed at baseline (BL) prior to TRT, TRT-12M, and Post-TRT. Eugonadal subjects did not receive treatment and were evaluated at comparable time points.

Results

There were no significant differences between groups prior to TRT at BL for any of the study endpoints. In the hypogonadal group, a significant increase in LTM was observed from BL to TRT-12M (50.2 ± 7.4 vs. 52.9 ± 6.8 kg, P < 0.01), which persisted Post-TRT compared to BL (52.2 ± 7.8 kg, P < 0.05). The increase in REE from BL to TRT-12M (1283 ± 246 vs. 1410 ± 250 kcal/day) was also retained at Post-TRT (1393 ± 220 kcal/day). These sustained improvements in LTM and REE after termination of anabolic hormonal therapy may be associated with persistent beneficial effects on health and physical function of hypogonadal men with chronic SCI.     

Heart Rate Response During Underwater Treadmill Training in Adults with Incomplete Spinal Cord Injury

Background:

Walking on a submerged treadmill can improve mobility in persons displaying lower limb muscle weakness and balance deficits. Little is known, however, regarding the effect of water treadmill exercise on cardiac performance in persons with incomplete spinal cord injury (iSCI).

Objective:

To assess heart rate response during underwater treadmill training (UTT) in adults with iSCI.

Methods:

Seven males and 4 females with iSCI (age = 48 ± 13 years; 5 ± 8 years after injury) completed 8 weeks of UTT (3 sessions per week; 3 walks per session) incorporating individually determined walking speeds, personalized levels of body weight unloading, and gradual, alternating increases in speed and duration. Heart rate was monitored during the last 15 seconds of the final 2 minutes of each walk.

Results:

Over the course of 3 biweekly periods in which walking speed remained constant, heart rate fell by 7% (7 ± 1 b•min^-1; P < .001) in weeks 2 and 3, 14% (17 ± 6 b•min^-1; P < .001) in weeks 4 and 5, and 17% (21 ± 11 b•min^-1; P < .001) in weeks 6 and 7.

Conclusion:

In adults with iSCI, progressively greater absolute and relative reductions in submaximal exercise heart rate occurred after 2 months of UTT featuring a systematic increase in training volume.     

Late outcome analysis of the Braile Biomédica? pericardial valve in the aortic position

Objective

Aortic valve replacement with Braile bovine pericardial prosthesis has been routinely done at the Heart Institute of the Universidade de São Paulo Medical School since 2006. The objective of this study is to analyze the results of Braile Biomédica^® aortic bioprosthesis in patients with aortic valve disease.

Methods

We retrospectively evaluated 196 patients with aortic valve disease submitted to aortic valve replacement with Braile Biomédica^® bovine pericardial prosthesis, between 2006 and 2010. Mean age was 59.41±16.34 years and 67.3% were male. Before surgery, 73.4% of patients were in NYHA functional class III or IV.

Results

Hospital mortality was 8.16% (16 patients). Linearized rates of mortality, endocarditis, reintervention, and structural dysfunction were 1.065%, 0.91%, 0.68% and 0.075% patients/year, respectively. Actuarial survival was 90.59±2.56% in 88 months. Freedom from reintervention, endocarditis and structural dysfunction was respectively 91.38±2.79%, 89.84±2.92% and 98.57±0.72% in 88 months.

Conclusion

The Braile Biomédica^® pericardial aortic valve prosthesis demonstrated actuarial survival and durability similar to that described in the literature, but further follow up is required to assess the incidence of prosthetic valve endocarditis and structural dysfunction in the future.     

Effects of underwater treadmill training on leg strength,balance, and walking performance in adults with incomplete spinal cord injury

Objective

To document the effects of underwater treadmill training (UTT) on leg strength, balance, and walking performance in adults with incomplete spinal cord injury (iSCI).

Design

Pre-test and post-test design.

Setting

Exercise physiology laboratory.

Participants

Adult volunteers with iSCI (n = 11).

Intervention

Participants completed 8 weeks (3 × /week) of UTT. Each training session consisted of three walks performed at a personalized speed, with adequate rest between walks. Body weight support remained constant for each participant and ranged from 29 to 47% of land body weight. Increases in walking speed and duration were staggered and imposed in a gradual and systematic fashion.

Outcome measures

Lower-extremity strength (LS), balance (BL), preferred and rapid walking speeds (PWS and RWS), 6-minute walk distance (6MWD), and daily step activity (DSA).

Results

Significant (P < 0.05) increases were observed in LS (13.1 ± 3.1 to 20.6 ± 5.1 N·kg⁻¹), BL (23 ± 11 to 32 ± 13), PWS (0.41 ± 0.27 to 0.55 ± 0.28 m·s⁻¹), RWS (0.44 ± 0.31 to 0.71 ± 0.40 m·s⁻¹), 6MWD (97 ± 80 to 177 ± 122 m), and DSA (593 ± 782 to 1310 ± 1258 steps) following UTT.

Conclusion

Physical function and walking ability were improved in adults with iSCI following a structured program of UTT featuring individualized levels of body weight support and carefully staged increases in speed and duration. From a clinical perspective, these findings highlight the potential of UTT in persons with physical disabilities and diseases that would benefit from weight-supported exercise.     

Pressure support-ventilation versus spontaneous breathing with "T-Tube" for interrupting the ventilation after cardiac operations

Objective

To compare pressure-support ventilation with spontaneous breathing through a T-tube for interrupting invasive mechanical ventilation in patients undergoing cardiac surgery with cardiopulmonary bypass.

Methods

Adults of both genders were randomly allocated to 30 minutes of either pressure-support ventilation or spontaneous ventilation with "T-tube" before extubation. Manovacuometry, ventilometry and clinical evaluation were performed before the operation, immediately before and after extubation, 1h and 12h after extubation.

Results

Twenty-eight patients were studied. There were no deaths or pulmonary complications. The mean aortic clamping time in the pressure support ventilation group was 62 ± 35 minutes and 68 ± 36 minutes in the T-tube group (P=0.651). The mean cardiopulmonary bypass duration in the pressure-support ventilation group was 89 ± 44 minutes and 82 ± 42 minutes in the T-tube group (P=0.75). The mean Tobin index in the pressure support ventilation group was 51 ± 25 and 64.5 ± 23 in the T-tube group (P=0.153). The duration of intensive care unit stay for the pressure support ventilation group was 2.1 ± 0.36 days and 2.3 ± 0.61 days in the T-tube group (P=0.581). The atelectasis score in the T-tube group was 0.6 ± 0.8 and 0.5 ± 0.6 (P=0.979) in the pressure support ventilation group. The study groups did not differ significantly in manovacuometric and ventilometric parameters and hospital evolution.

Conclusion

The two trial methods evaluated for interruption of mechanical ventilation did not affect the postoperative course of patients who underwent cardiac operations with cardiopulmonary bypass.     

Repair of aortic root in patients with aneurysm or dissection: comparing the outcomes of valve-sparing root replacement with those from the Bentall procedure

Introduction

Management of aortic root aneurysm or dissection has been the subject of much discussion that has led to some modifications. The current trend is a valve-sparing root replacement. We compared the outcome following valve sparing root repair with Bentall procedure.

Methods

We retrospectively evaluated 70 patients who underwent root replacement for aneurysm or dissection and compared the outcomes of valve-sparing root replacement with those of the Bentall procedure from January 2007 to December 2011 at our institution.

Results

Twenty-five patients had valve-sparing aortic root replacement (VSR, including reimplantation or remodeling) (23 males and 2 females), and 45 patients had the Bentall procedure (34 males and 11 females). Patients who underwent a VSR were younger with a mean age of 55.4 ± 14.8 years compared to those who underwent the Bentall procedure with a mean age of 60.6 ± 12.7 (P=ns). The preoperative aortic insufficiency (AI) in the VSR group was moderate in 8 (32%) patients, and severe in 6 (24%). Preoperative creatinine was 1 ± 0.35 mg/dl in the VSR group and 1.1 ± 0.87 mg/dl in the Bentall group. In the VSR group, 3 (12%) patients had emergency surgery; by contrast, in the Bentall group, 8 (17%) patients had emergent surgery. Concomitant coronary artery bypass grafting (excluding coronary reimplantation) was performed in 8 (32%) patients in the VSR group and in 12 (26.6%) patients in the Bentall group (P=0.78); additional valve procedures were performed in 2 (8%) patients in the VSR group and in 11 (24.4%) patients in the Bentall group. The perioperative mortality was 8% (n=2) and 13.3% (n=6), for the VSR and Bentall procedures, respectively (P=0.7, ns). The total duration of intensive care unit stay was 116.6 ± 106 hours for VSR patients and 152.5 ± 218.2 hours for Bentall patients (P=0.5). The overall length of stay in the hospital was 10 ± 8.1 days for VSR and 11 ± 9.52 days for Bentall (P=0.89). The one-year survival was 92% for the VSR group and 79.0% for the Bentall group. The seven-year survival for the VSR group was 92% and 79% for the Bentall group (95% CI [1.215 to 0.1275], P=0.1).

Conclusion

Aortic valve-sparing root replacement can be performed with acceptable morbidity and mortality with a comparable long-term survival to the Bentall procedure.     

Volume and Contact Surface Area Analysis of Bony Tunnels in Single and Double Bundle Anterior Cruciate Ligament Reconstruction Using Autograft Tendons: In Vivo Three-Dimensional Imaging Analysis

Background

Regarding reconstruction surgery of the anterior cruciate ligament (ACL), there is still a debate whether to perform a single bundle (SB) or double bundle (DB) reconstruction. The purpose of this study was to analyze and compare the volume and surface area of femoral and tibial tunnels during transtibial SB versus transportal DB ACL reconstruction.

Methods

A consecutive series of 26 patients who underwent trantibial SB ACL reconstruction and 27 patients with transportal DB ACL reconstruction using hamstring autograft from January 2010 to October 2010 were included in this study. Three-dimensional computed tomography (3D-CT) was taken within one week after operation. The CT bone images were segmented with use of Mimics software v14.0. The obtained digital images were then imported in the commercial package Geomagic Studio v10.0 and SketchUp Pro v8.0 for processing. The femoral and tibial tunnel lengths, diameters, volumes and surface areas were evaluated. A comparison between the two groups was performed using the independent-samples t-test. A p-value less than the significance value of 5% (p < 0.05) was considered statistically significant.

Results

Regarding femur tunnels, a significant difference was not found between the tunnel volume for SB technique (1,496.51 ± 396.72 mm³) and the total tunnel volume for DB technique (1,593.81 ± 469.42 mm³; p = 0.366). However, the total surface area for femoral tunnels was larger in DB technique (919.65 ± 201.79 mm²) compared to SB technique (810.02 ± 117.98 mm²; p = 0.004). For tibia tunnels, there was a significant difference between tunnel volume for the SB technique (2,070.43 ± 565.07 mm³) and the total tunnel volume for the DB technique (2,681.93 ± 668.09 mm³; p ≤ 0.001). The tibial tunnel surface area for the SB technique (958.84 ± 147.50 mm²) was smaller than the total tunnel surface area for the DB technique (1,493.31 ± 220.79 mm²; p ≤ 0.001).

Conclusions

Although the total femoral tunnel volume was similar between two techniques, the total surface area was larger in the DB technique. For the tibia, both total tunnel volume and the surface area were larger in DB technique.     

Single-Incision Laparoscopic Surgery Versus Standard Laparoscopic Surgery for Unroofing of Hepatic Cysts

Background and Objectives:

The aim of this report is to document the feasibility and safety of umbilical single-incision laparoscopic liver cyst unroofing in the treatment of simple hepatic cysts in a retrospective case-control study. We also introduce some operative skills for single-incision laparoscopic surgery.

Methods:

From May 2009 to July 2011, 15 patients underwent umbilical single-incision laparoscopic liver cyst unroofing. All the clinical data were retrospectively analyzed. Another 15 simple liver cyst patients who received standard laparoscopic liver cyst unroofing at our hospital during the same period—with a similar age, nature of the cyst, and position to the single-incision group—were selected to undergo a case-control study. The operative time, blood loss, recovery time of gastrointestinal function, volume of postoperative drainage, postoperative drainage time, postoperative hospitalization time, and postoperative recurrence rate were compared between the two groups.

Results:

There was no significant difference between the single-incision group and standard group in operative time (58.3 ± 7.43 minutes vs 58.7 ± 6.14 minutes), blood loss (17.0 ± 3.19 mL vs 14.7 ± 1.86 mL), recovery time of gastrointestinal function (2.5 ± 0.22 days vs 2.4 ± 0.22 days), volume of postoperative drainage (408.0 ± 119.5 mL vs 450.0 ± 89.5 mL), postoperative drainage time (2.6 ± 0.55 days vs 3.7 ± 0.59 days), or postoperative hospitalization time (4.8 ± 0.44 days vs 5.2 ± 0.56 days) (P > .05). The postoperative follow-up period was 1 to 24 months.

Conclusions:

Compared with standard laparoscopic liver cyst unroofing, single-incision laparoscopic liver cyst unroofing shows no significant difference during the overall treatment process. In addition to the advantages of less trauma, more rapid recovery, and shorter hospital stay, single-incision laparoscopic surgery can reach the effect of “no scar” and can be safely and effectively carried out.     

Results of Revision Surgery and Causes of Unstable Total Knee Arthroplasty

Background

The aim of this study was to evaluate causes of unstable total knee arthroplasty and results of revision surgery.

Methods

We retrospectively reviewed 24 knees that underwent a revision arthroplasty for unstable total knee arthroplasty. The average follow-up period was 33.8 months. We classified the instability and analyzed the treatment results according to its cause. Stress radiographs, postoperative component position, and joint level were measured. Clinical outcomes were assessed using the Hospital for Special Surgery (HSS) score and range of motion.

Results

Causes of instability included coronal instability with posteromedial polyethylene wear and lateral laxity in 13 knees, coronal instability with posteromedial polyethylene wear in 6 knees and coronal and sagittal instability in 3 knees including post breakage in 1 knee, global instability in 1 knee and flexion instability in 1 knee. Mean preoperative/postoperative varus and valgus angles were 5.8°/3.2° (p = 0.713) and 22.5°/5.6° (p = 0.032). Mean postoperative α, β, γ, δ angle were 5.34°, 89.65°, 2.74°, 6.77°. Mean changes of joint levels were from 14.1 mm to 13.6 mm from fibular head (p = 0.82). The mean HSS score improved from 53.4 to 89.2 (p = 0.04). The average range of motion was changed from 123° to 122° (p = 0.82).

Conclusions

Revision total knee arthroplasty with or without a more constrained prosthesis will be a definite solution for an unstable total knee arthroplasty. The solution according to cause is very important and seems to be helpful to avoid unnecessary over-constrained implant selection in revision surgery for total knee instability.     

Comparison of laparoscopic and open cystectomy for bladder cancer: a single center of 110 cases report

Purpose

We compared the operative time, complications, blood loss, total cost, and hospital days of laparoscopic cystectomy vs. open cystectomy for bladder cancer.

Materials and methods

This retrospective, nonrandomized study was conducted between January 2004 and March 2011 on 110 patients (17 women and 93 men) who underwent radical cystectomy for bladder cancer. A total of 45 cystectomies were performed laparoscopically and 65 by open surgery. Mean patient age was 62.9±10.4 years. The age, gender, American Society of Anesthesiologists score, histopathological results etc. were reviewed in this article.

Results

Intraoperative blood loss was significantly lower in the laparoscopic surgery group (821±776 vs. 1112±706 mL, P=0.044) while operative time was significantly lower in the open surgery group (376±90 vs. 445±119 min, P=0.001). The total costs were also significantly lower in the open surgery group 51,726±13,589 yuan (about $8000) vs. 63,053±19,378 yuan (about $10,000), P<0.001). There was no statistically significant difference in complication rates, postoperative days in hospital between the two groups.

Conclusions

Laparoscopic cystectomy can reduce intraoperative blood loss significantly. Open cystectomy requires less operative time and has a lower cost than laparoscopic cystectomy for bladder cancer. There was no statistically significant difference in postoperative complication rates in the hospital between the two groups.KEY WORDS : Bladder cancer, cystectomy, laparoscopy surgery, open surgery     

Effects of Acute Nitric Oxide Synthase Inhibition on Lower Leg Vascular Function in Chronic Tetraplegia

Background/Objective:

To improve our understanding of the lower-leg vascular responses of nitric oxide synthase inhibition in persons with tetraplegia.

Participants:

Six people with chronic tetraplegia and 6 age-matched controls.

Methods:

Lower-leg relative vascular resistance and venous volume variation were obtained by venous occlusion plethysmography and blood pressure by auscultation at baseline. Postintravenous infusion of the nitric oxide synthase inhibitor N^G-nitro-l-arginine-methyl-ester (1 mg·kg⁻¹) or placebo on separate days.

Results:

At baseline in the group with tetraplegia compared with controls, mean arterial pressure and relative vascular resistance of the leg were significantly lower. After nitric oxide synthase inhibition, mean arterial pressure and lower leg vascular resistance were significantly elevated in both groups. There were no group or intervention differences in venous volume variation.

Conclusion:

These preliminary results suggest that nitric oxide synthase inhibition with 1 mg·kg⁻¹ N^G-nitro-l-arginine-methyl-ester normalizes seated blood pressure and lower leg vascular resistance to control group baseline levels.     

Trunk strength and function using the multidirectional reach distance in individuals with non-traumatic spinal cord injury

Context

Trunk control is essential to engage in activities of daily living. Measuring trunk strength and function in persons with spinal cord injury (SCI) is difficult. Trunk function has not been studied in non-traumatic SCI (NTSCI).

Objectives

To characterize changes in trunk strength and seated functional reach in individuals with NTSCI during inpatient rehabilitation. To determine if trunk strength and seated reach differ between walkers and wheelchair users. To explore relationships between trunk and hip strength and seated functional reach.

Design

Observational study.

Setting

Two SCI rehabilitation facilities.

Participants

32 subacute inpatients (mean age 48.0 ± 15.4 years).

Outcome measures

Isometric strength of trunk and hip and function (Multidirectional Reach Test: MDRT) were assessed at admission and within 2 weeks of discharge. Analysis of variance was conducted for admission measures (MDRT, hip and trunk strength) between walkers and wheelchair users. Changes in MDRT, hip and trunk strength were evaluated using parametric and non-parametric statistics. The level of association between changes in values of MRDT and strength was also examined.

Results

Significant differences between walkers and wheelchair users were found for strength measures (P < 0.05) but not for MDRT. Left- and right-sided reaches increased in wheelchair users only (P < 0.05). Associations between changes in hip strength, trunk strength, and reach distance were found (R = 0.67–0.73).

Conclusion

In clinical settings, it is feasible and relevant to assess trunk, hip strength, and MRDT. Future studies require strategies to increase the number of participants assessed, in order to inform clinicians about relevant rehabilitation interventions.     

Surgical Management of Adnexal Masses in Pregnancy

Background and Objectives:

Our objective was to review the surgical management, surgical outcomes, and obstetric outcomes of adnexal masses in pregnancy.

Methods:

A retrospective review was performed of pregnant women before 20 weeks of gestation who underwent laparoscopy or laparotomy for management of an adnexal mass during the period of January 2005 to June 2012 at a university-affiliated hospital.

Results:

Thirty-five pregnant women underwent surgical removal of adnexal masses during the 7.5-year study period: 21 (60.0%) underwent laparoscopic surgery, and 14 (40.0%) underwent laparotomy. The left upper quadrant entry technique was used in 20 women. Conversion to laparotomy was required in 2 women because of extensive pelvic adhesions. The mean gestational age at surgery was 15.2 ± 1.9 weeks. All women had undergone ovarian cystectomy. A malignant mass was found in 3 (8.6%) women. The laparoscopy group had a significantly less blood loss (67.4 ± 55.8 vs 153.6 ± 181.0 mL, P = .048) and shorter mean hospital stay (2.8 ± 1.0 vs 3.8 ± 1.1 days, P = .006) than the laparotomy group. One woman miscarried soon after surgery. There was no significant difference in obstetric outcomes between the laparoscopy and laparotomy groups.

Conclusion:

Surgical management of adnexal masses during pregnancy appears to have favorable outcomes for the mother and the fetus.     

Acute Suppression of Bone Turnover With Calcium Infusion in Persons With Spinal Cord Injury

Background:

Some people with chronic spinal cord injury (SCI) have low vitamin D levels and secondary hyperparathyroidism.

Objective:

To determine whether, and to what extent, an acute calcium infusion decreased levels of N-telopeptide (NTx), a marker of osteoclastic activity, in individuals with chronic SCI.

Study Design:

Case series.

Subjects:

Eight men with chronic SCI. A relatively low serum 25 hydroxyvitamin D concentration (25[OH]D ≤20 ng/mL) and/or a high parathyroid hormone (PTH) (>55 pg/mL) was a prerequisite for study inclusion.

Methods:

Calcium gluconate bolus 0.025 mmol elemental calcium/kg over 20 minutes followed by a constant infusion of 0.025 mmol/kg per hour for 6 hours was infused; blood samples were collected every 2 hours for measurement of serum total calcium, creatinine, NTx, and PTH.

Results:

All results are expressed as means (± SDs). Baseline serum 25-hydroxyvitamin D level was 14.5 ± 3.5 ng/mL (range: 10.2–19.6 ng/mL); PTH, 70 ± 25 pg/mL (range: 37–100 pg/mL); and NTx, 21 ± 7 nM bone collagen equivalents (BCE) (range: 14–34 nM). At 2, 4, and 6 hours after the calcium infusion, serum calcium rose from 9.3 ± 0.2 to 10.8 ± 0.9, 10.5 ± 0.8, and 10.6 ± 0.6 mg/d; PTH was suppressed from 70 ± 25 pg/mL to 18 ± 12, 16 ± 9, and 15 ± 9 pg/mL, respectively; NTx fell from 21 ± 8 nM BCE to 17 ± 5, 12 ± 4, and 12 ± 3 nM BCE, respectively.

Conclusions:

Serum NTx is a marker for bone collagen catabolism, and its reduction suggests that bone turnover was decreased. A relative deficiency of vitamin D associated with chronically elevated levels of PTH would be expected to increase bone turnover and to worsen the bone loss associated with immobilization.     

Outcomes of infection following pediatric spinal fusion

Background

Removal of instrumentation is often recommended as part of treatment for spinal infections, but studies have reported eradication of infection even with instrumentation retention by using serial débridements and adjuvant antibiotic pharmacotherapy. We sought to determine the effect of instrumentation retention or removal on outcomes in children with spinal infections.

Methods

We retrospectively reviewed the cases of patients who experienced early (< 3 mo) or late (≥ 3 mo) infected spinal fusions. Patients were evaluated at least 2 years after eradication of the infection using the following protocol outcomes: follow-up Cobb angle, curve progression and nonunion rates.

Results

Our sample included 35 patients. The mean age at surgery was 15.1 ± 6.0 years, 65.7% were girls, and mean follow-up was 41.7 ± 26.9 months. The mean Cobb angle was 63.6° ± 14.5° preoperatively, 29.4° ± 16.5° immediately after surgery and 37.2° ± 19.6° at follow-up. Patients in the implant removal group (n = 21) were more likely than those in the implant retention group (n = 14) to have a lower ASA score (71.4% v. 28.6%, p = 0.03), fewer comorbidities (66.7% v. 21.4%, p = 0.03), late infections (81.0% v. 14.3%, p = 0.01) and deep infections (95.2% v. 64.3%, p = 0.03). Implants were retained in 12 of 16 (75.0%) patients with early infections and 2 of 19 (10.5%) with late infections. Patients with implant removal had a higher pseudarthrosis rate (38.1% v. 0%, p = 0.02) and a faster curve progression rate (5.8 ± 9.8° per year v. 0.2 ± 4.7° per year, p = 0.04).

Conclusion

Implant retention should be considered, irrespective of the timing or depth of the infection.     

Revision knee arthroplasty with a rotating-hinge design in elderly patients with instability following total knee arthroplasty

Background

Revision knee arthroplasty with a rotating-hinge design could be an option for the treatment of instability following total knee arthroplasty (TKA) in elderly patients.

Purpose

To evaluate the clinical and radiographic results of revision arthroplasties in TKAs with instability using a rotating-hinge design in elderly patients.

Methods

We retrospectively reviewed 96 rotating-hinge arthroplasties. The average age of the patients was 79 years (range, 75–86 years); the minimum follow-up was 5 years (mean, 7.3 years; range, 5–10 years). Patients were evaluated clinically (Knee Society score) and radiographically (position of prosthetic components, signs of loosening, bone loss).

Results

At a minimum followup of 5 years (mean, 7.3 years; range, 5–10 years), Knee Society pain scores improved from 37 preoperatively to 79 postoperatively, and function scores improved from 34 to 53. ROM improved on average from −15° of extension and 80° of flexion before surgery to −5° of extension and 120° of flexion at the last followup (p = 0.03). No loosening of implants was observed. Nonprogressive radiolucent lines were identified around the femoral and tibial components in 2 knees. One patient required reoperation because of a periprosthetic infection.

Conclusions

Revision arthroplasty with a rotating-hinge design provided substantial improvement in function and a reduction in pain in elderly patients with instability following TKA.

Level of evidence

Level IV, therapeutic study.