Multidisciplinary approach toward enhanced recovery after surgery for total knee arthroplasty improves outcomes

Knee osteoarthritis is a degenerative disorder of the knee,which leads to joint pain,stiffness,and inactivity and significantly affects the quality of life.With an increased prevalence of obesity and greater life expectancies,total knee arthroplasty(TKA)is now one of the major arthroplasty surgeries performed for knee osteoarthritis.When enhanced recovery after surgery(ERAS)was introduced in TKA,clinical outcomes were enhanced and the economic burden on the healthcare system was reduced.ERAS is an evidence-based scientific protocol aimed at ameliorating the surgical stress response.ERAS aims to enhance the recovery phase,which encompasses multidisciplinary strategies at every step of perioperative care,including the rehabilitation phase.Implementation of ERAS in TKA aids in reducing the length of hospital stay,improving pain management,reducing perioperative complications,and enhancing patient satisfaction.Multidisciplinary collaboration,integrating the expertise of anesthesiologists,orthopedic surgeons,nursing personnel,and other healthcare professionals,is the cornerstone of ERAS in patients undergoing TKA.

Recovery of sympathetic nerve function after lumbar sympathectomy is slower in the hind limbs than in the torso

Local sympathetic denervation by surgical sympathectomy is used in the treatment of lower limb ulcers and ischemia,but the restoration of cutaneous sympathetic nerve functions is less clear.This study aims to explore the recovery of cutaneous sympathetic functions after bilateral L2-4 sympathectomy.The skin temperature of the left feet,using a point monitoring thermometer,increased intraoperatively after sympathectomy.The cytoplasm of sympathetic neurons contained tyrosine hydroxylase and dopamineβ-hydroxylase,visualized by immunofluorescence,indicated the accuracy of sympathectomy.Iodine starch test results suggested that the sweating function of the hind feet plantar skin decreased 2 and 7 weeks after lumbar sympathectomy but had recovered by 3 months.Immunofluorescence and western blot assay results revealed that norepinephrine and dopamineβ-hydroxylase expression in the skin from the sacrococcygeal region and hind feet decreased in the sympathectomized group at 2 weeks.Transmission electron microscopy results showed that perinuclear space and axon demyelination in sympathetic cells in the L5 sympathetic trunks were found in the sympathectomized group 3 months after sympathectomy.Although sympathetic denervation occurred in the sacrococcygeal region and hind feet skin 2 weeks after lumbar sympathectomy,the skin functions recovered gradually over 7 weeks to 3 months.In conclusion,sympathetic functional recovery may account for the recurrence of hyperhidrosis after sympathectomy and the normalization of sympathetic nerve trunks after incomplete injury.The recovery of sympathetic nerve function was slower in the limbs than in the torso after bilateral L（2-4） sympathectomy.

Kinetics of testosterone recovery in clinically localized prostate cancer patients treated.with radical prostatectomy and subsequent short-term adjuvant androgen deprivation therapy

deprivation therapy （ADT） is a standard treatment for metastatic, recurrent and locally advanced prostate cancer （PCa）. The aim of this study is to investigate the timing and extent of testosterone recovery in clinically localized PCa patients treated with radical prostatectomy （RP） and subsequent short-term adjuvant ADT. A total of 95 localized PCa patients underwent RP and 9-month adjuvant ADT were included in this prospective study. Serum testosterone level was measured before adjuvant ADT, at ADT cessation, and at 1, 3, 6, 9 and 12 months after cessation of ADT. A Cox proportional hazards model was used to assess variables associated with the ti me of testosterone normalization. The results showed that median patient age was 67 years and median testosterone level before adjuvant ADT was 361 （230-905） ng d1-1. All patients finished 9-month adjuvant ADT and achieved castrate testosterone level. At 3 months after ADT cessation, testosterone recovered to supracastrate level in 97.9% patients and to normal level in 36.9% patients. The percentage of patients who recovered to normal testosterone level increased to 66.3%, 86.3% and 92.6% at 6, 9 and 12 months, respectively. Cox regression model found that higher baseline testosterone level （ 300 ng dl- 1） was the only variable associated with a shorter time to testosterone normalization （hazard ratio： 1.98; P -- 0.012）. In conclusion, in most patients, testosterone recovered to supracastrate level at 3 months and to normal level at 12 months after 9-month adjuvant ADT cessation. Patients with higher baseline testosterone level need shorter time of testosterone normalization.

Effect of bowel rehabilitative therapy on structural adaptation of remnant small intestine: animal experiment

AIM: To investigate the individual and the combined effects of glutamine, dietary fiber, and growth hormone on the structural adaptation of the remnant small bowel. METHODS: Forty-two adult male Sprague-Dawley rats underwent 85% mid-small bowel resection and received total parenteral nutrition (TPN) support during the first three postoperational days.From the 4th postoperational day, animals were randomly assigned to receive 7 different treatments for 8 days: TPNcon group, receiving TPN and enteral 20 g x L(-1) glycine perfusion; TPN+Gln group, receiving TPN and enteral 20 g x L(-1) glutamine perfusion; ENcon group, receiving enteral nutrition (EN) fortified with 20 g x L(-1) glycine; EN+Gln group, enteral nutrition fortified with 20 g x L(-1) glutamine; EN+Fib group, enteral nutrition and 2 g x d(-1) oral soybean fiber; EN+GH group, enteral nutrition and subcutaneous growth hormone (GH) (0.3 IU) injection twice daily; and ENint group, glutamine-enriched EN, oral soybean fiber, and subcutaneous GH injection. RESULTS: Enteral glutamine perfusion during TPN increased the small intestinal villus height (jejunal villus height 250 microm +/- 29 microm in TPNcon vs 330 microm +/- 54 microm in TPN+Gln, ileal villus height 260 microm +/- 28 microm in TPNcon vs 330 microm +/- 22 microm in TPN+Gln, P【0.05) and mucosa thickness (jejunal mucosa thickness 360 microm +/- 32 microm in TPNcon vs 460 microm +/- 65 microm in TPN+Gln, ileal mucosa thickness 400 microm +/- 25 microm in TPNcon vs 490 microm +/- 11 microm in TPN+Gln,P【 0.05) in comparison with the TPNcon group. Either fiber supplementation or GH administration improved body mass gain (end body weight 270 g +/- 3.6g in EN+Fib, 265.7 g +/- 3.3 g in EN+GH, vs 257 g +/- 3.3 g in ENcon, P【 0.05), elevated plasma insulin-like growth factor (IGF-I) level (880 microg x L(-1). 52 microg x L-(-1) in EN+Fib,1200 microg x L(-1). 96 microg x L-(-1) in EN +/- GH, vs 620 microg x L(-1).43 microg x L-(-1) in ENcon, P【 0.05), and increased the villus height (jejunum 560 microm +/- 44 microm in EN +/- Fib, 530 microm +/- 30 microm in EN +/- GH, vs 450 microm +/- 44 microm in ENcon, ileum 400 microm +/- 30 microm in EN+Fib, P【0.05) and the mucosa thickness (jejunum 740 microm +/- 66 microm in EN +/- Fib, 705 microm +/- 27 microm in EN +/- GH, vs 608 microm +/- 58 microm in ENcon, ileum 570 microm +/- 27 microm in EN +/- Fib, 560 microm +/- 56 microm in remnant jejunum and ileum. Glutamine-enriched EN produced little effect in body mass, plasma IGF-I level, and remnant small bowel mucosal structure. The ENint group had greater body mass (280 g +/- 2.2g), plasma IGF-I level (1450 microg x L(-1). 137 microg x L-(-1)), and villus height (jejunum 620 microm +/- 56 microm, ileum 450 microm +/- 31 microm) and mucosal thickness (jejunum 800 microm +/- 52 microm, ileum 633 microm +/- 33 microm) than those in ENcon, EN+Gln (jejunum villus height and mucosa thickness 450 microm +/- 47 microm and 610 +/- 63 microm, ileum villus height and mucosa thickness 330 microm +/- 39 microm and 500 microm +/- 52 microm), EN+GH groups (P【0.05), and than those in EN+Fib group although no statistical significance was attained. CONCLUSION: Both dietary fiber and GH when used separately can enhance the postresectional small bowel structural adaptation. Simultaneous use of these two gut-trophic factors can produce synergistic effects on small bowel structural adaptation. Enteral glutamine perfusion is beneficial in preserving small bowel mucosal structure during TPN, but has little beneficial effect during EN.

Selective neuronal PTEN deletion：can we take the brakes off of growth without losing control？

The limited ability for injured adult axons to regenerate is a major cause for limited functional recovery after injury to the nervous system,motivating numerous efforts to uncover mechanisms capable of enhancing regeneration potential.One promising strategy involves deletion or knockdown of the phosphatase and tensin（PTEN） gene.Conditional genetic deletion of PTEN before,immediately following,or several months after spinal cord injury enables neurons of the corticospinal tract（CST） to regenerate their axons across the lesion,which is accompanied by enhanced recovery of skilled voluntary motor functions mediated by the CST.Although conditional genetic deletion or knockdown of PTEN in neurons enables axon regeneration,PTEN is a well-known tumor suppressor and mutations of the PTEN gene disrupt brain development leading to neurological abnormalities including macrocephaly,seizures,and early mortality.The long-term consequences of manipulating PTEN in the adult nervous system,as would be done for therapeutic intervention after injury,are only now being explored.Here,we summarize evidence indicating that long-term deletion of PTEN in mature neurons does not cause evident pathology; indeed,cortical neurons that have lived without PTEN for over 1 year appear robust and healthy.Studies to date provide only a first look at potential negative consequences of PTEN deletion or knockdown,but the absence of any detectable neuropathology supports guarded optimism that interventions to enable axon regeneration after injury are achievable.

Olfactory ensheathing cell transplantation in 106 patients with old spinal cord injury Differences in ages,sexes,disease courses,injured types and sites

BACKGROUND： It has been demonstrated that the transplantation of olfactory ensheathing cell （OEC） can promote the recovery of neurological function through ameliorating the local internal environment in spinal cord injury. OBJECTIVE： To evaluate the recent efficacy of OEC transplantation on old spinal cord injury. DESIGN： A self-controlled experiment. SETTING： Department ofNeurosurgery, Taian Rongjun Hospital of Shandong Province. PARTICIPANTS： Totally 106 inpatients with old spinal cord injury were selected from the Department of Neurosurgery, Taian Rongjun Hospital of Shandong Province from June 2004 to December 2006, including 97 males and 9 females. Inclusive criteria： ① Complete data; ② Informed with the fact; ③No further recover neurological function after drug therapy （neurotrophic factor, GM-1）, traditional Chinese medicine, physiotherapy and rehabilitative exercises; ④ No obvious compression of the injured spinal cord displayed by MRI examination. METHODS： ① The olfactory bulb was obtained from embryo of induced labor in middle pregnancy above 4 months supplied voluntarily by pregnant women, and the survived cells after purification and culture for 1 - 2 weeks were collected. Dura mater was incised by posterior approach, then the cultured OEC suspension was transplanted to corresponding regions by means of multi-target injection using microscope. ② The patients were evaluated for twice with the standards suggested by American Spinal Injury Association （ASIA） at admission and 2 - 4 weeks postoperatively, in order to investigate the efficacy in different age groups, different sites and at different time points after the OEC transplantation. ③ Standards for evaluation： The International Standard for Neurological and Functional Classification of Spinal Cord Injury set by ASIA： The highest score of motor function was 100 points; The highest score of sensory function was 112 points for light touch and 112 for acupuncture sense. Frankel grading modified by ASIA in 1992： grades A, B, C, D and E （grade A for complete injury, and grade E for normal）. ④ The data were statistically processed by Professor Cheng from the Department of Statistics, Taishan Medical College. MAIN OUTCOME MEASURES： Changes of motor and sensory functions postoperatively. RESULTS： All the 106 patients with old spinal cord injury were involved in the analysis of results. Grade A （n =72） at admission recovered to grade B in 31 cases and grade C in 7 cases after operation; Grade B （n =9） recovered to grade C in 2 cases; Grade C （n =15） recovered to grade D in 4 cases; Grade D （n =10） recovered to grade E in 1 cases, which referred to normal sensory and motor functions. The scores of motor, tactile sensation and pain sensation postoperatively were all obviously higher than those at admission （t =5.381, 7.036, 7.775, P 〈 0.05）. The recovery of motor function had obvious difference among patients of different ages （F =5.235, P =0.001）. There were no obvious differences in the recovery of motor and sensory functions among patients of different sexes, courses, injured types and sites. CONCLUSION： The neurological function can be ameliorated in a short time after OEC transplantation in patients with old spinal cord injury. The efficacy is generally the same in patients of different sexes, courses, injured types and sites, but there are differences in the effects on motor function of patients of different ages.

The strength and function of hip abductors following anterolateral minimally invasive total hip arthroplasty

Objective： To analyze the extent of postoperative hip abductor insufficiency in primary total hip arthroplasty （THA） patients undergoing anterolateral minimally invasive （ALM1） approach, and to investigate whether the clinical outcomes are more favorable in femoral neck fracture （FNF） patients than in non-femoral neck fracture （nFNF） patients. Methods： A total of 48 patients were enrolled in this study. Each patient underwent a clinical examination preoperatively and 6, 12, 24 and 48 weeks postoperatively. The abductor torque, Trendelenburg＇s sign, gait velocity, Harris hip score, Oxford hip score, Westren Ontario and McMaster Universities （WOMAC） score and visual analog scale pain score were recorded. Statistical evaluation was performed with SPSS software version 18.0. The significance level was set at P〈0.05. Results： The abductor torque of the operated hip and the recovery ratio showed a gradual improving tendency from 6 weeks postoperatively until the last follow-up. Gait velocity, Harris hip score, Oxford hip score and WOMAC score improved significantly after the operation until 24 weeks postoperatively. In the FNF group, the abductor torque of the operated side and the recovery ratio were significantly higher than in nFNF group at 6 weeks postoperatively, however, as time passed, this trend tended to disappear. Conclusion： This study demonstrates that patients can obtain good abductor strength and function in the early postoperative period and the hip abductor function of patients who suffer from hip osteoarthritis, rheumatoid arthritis, avascular necrosis of the femoral head could be significantly improved following ALMI THA.

Functional reconstruction of ischemic contracture in the lower limb

Objective： To discuss the method of functional reconstruction of ischemic contracture in the lower limb and propose a classification protocol for ischemic contracture in the lower limb based on its severity and prognosis. Methods： Atotal of 42 patients with ischemic contracture in the lower limb were included in this study. According to different types of disturbance and degrees of severity, surgical reconstructions consisting of nerve decompression, tendon lengthening or transfer, intrinsic foot muscle release and sural-tibial nerve anastomosis were performed in every patient. Results： Postoperatively, all patients were able to walk on flat ground. Drop foot was corrected in 10 patients, and 5 patients still felt some difficulty during stair activity. Split Achilles tendon transfer to flexor hallucis longus tendon was performed in 12 patients, and their walking stability was improved. Seven patients accepted ipsilateral suraltibial nerve anastomosis, and sensitivity recovery reached to S2 in 2 patients and S3 in 5 patients. Conclusions： Iscbemic contracture in the lower limb is a devastating complication after lower limb trauma. The prevention of contracture is much more important than the treatment of an established contracture. Split Achilles tendon transfer to flexor hallucis longus tendon and sural-tibial nerve anastomosis, which was initially implemented by us, could improve the functional recovery of ischemic contracture in lower limbs, and thus provides a new alternative for functional reconstruction of ischemic contracture in the lower limb.

Clinical effect of distal radius fracture treated with open reduction and internal plate fixation

Background For some specific comminuted unstable intra-articular fracture,the plaster cast can not maintain the alignment of the articular surface effectively.The aim of this study was to evaluate the clinical effects of distal radius fracture treated with open reduction and internal plate fixation retrospectively.Methods From January 2002 to March 2010,539 cases of distal radius fracture were treated with open reduction and internal fixation,including 184 males and 355 females aging 21-72 years （mean 57 years）.Fractures were caused by falling to the ground in 459 cases,by traffic accident in 62 cases and by athletic injuries in 18 cases.Of 539 cases,there were 523 cases of closed fracture and 16 cases of open fracture.According to Arbeitsgemeinschaft fur Osteosynthesefragen （AO） standards of classification,there were 14 cases of A2 type,22 of A3 type,18 of B1 type,24 of B2 type,62 of B3 type,91 of C1 type,162 of C2 type and 146 of C3 type.The time from injury to operation was 1-16 days （mean 5 days）.All patitents received open reduction and internal plate screw fixation.Forty-seven patients with bone defect were given 6-15 g autologous ilium and 75 cases were given 5 ml calcium sulphate artificial aggregate after reduction.Results All incisions healed by first intention after operation.Patients were followed up for 15 to 32 months postoperatively （mean 22 months）.The fractures healed within 10-18 weeks after operation （mean 12 weeks）.During the last follow-up,the mean palmar tilt was （7.0±0.9）° and the mean ulnar variance was （21.0±4.2）°,showing significant difference when compared with preoperation （（-5.0±1.2）° and （8.0±3.8）°）.The radial heights were not abbreviated.According to Gartland and Werley assessment system,the results were excellent in 314 cases,good in 163 cases,fair in 46 cases,and poor in 16 cases 12 weeks after operation,the excellent and good rate was 88.5%.Conclusions The clinical effect of distal radius fracture treated with open reduction and internal plate fixation was relatively satisfactory.Meticulous operation procedure and individual rehabilitation strategy contribute to the wrist joint functional recovery.

Effect of basic fibroblast growth factor on the expression of glial fibrillary acidic protein after tractive spinal cord injury in rats

OBJECTIVE: To investigate the effects of basic fibroblast growth factor (bFGF) on the expression of glial fibrillary acidic protein (GFAP) after tractive spinal cord injury in rats and to explore the recovery of spinal cord function. METHODS: The rats were subjected to tractive spinal cord injury at T13-L2. Cortical somatosensory-evoked potential (CSEP) was closely monitored and when P1-N1 wave amplitude decreased to 70% of that before operation, a small-bore catheter was inserted below the injured plane through subarachnoid cavity. In the treatment groups, 20 microl of bFGF solution (containing 20 microg of bFGF) was injected through the catheter right after the operation and 1, 2, 3, 4, 8, 12 and 24 h postoperatively. In the control group, same volume of normal saline was injected and every four rats were killed at 1, 4, 7, 14 and 21 d after the operation. Combined behavior score (CBS) and electro-physiological examination were adopted to evaluate function recovery. Expression of GFAP was observed by immuno-histochemical staining and was analyzed quantitatively by computer image analysis. RESULTS: There was statistically significant difference in GFAP-positive cells between bFGF treatment group and the control group (P

Hemiparesis in carotid cavernous fistulas (CCFs): a case report and review of the literature

Carotid-cavernous fistulas (CCFs) are abnormal arteriovenous anastamoses between the carotid artery and the cavernous sinus. These fistulas may be classified by cause (spontaneous or traumatic), flow velocity (high or low), or pathogenesis (direct or indirect). The most commonly adopted classification is that described by Barrow based on arterial supply. Traumatic CCFs are almost always direct shunts between the internal carotid artery (ICA) and the cavernous sinus. General features of CCFs, which may be apparent with any lesion, including bruit, headache, loss of vision, altered mental status and neurological deficits. Some fistulae may present primarily with hemorrhage before any evaluation can be performed. However, hemiparesis has been rarely observed. Only a literature review of Murata et al reported a case of hemiparesis caused by posttraumatic CCF, in which the fistula resulted in venous hypertension and subsequent brainstem congestion. While in our case, cerebral infarction was caused by total steal of the blood flow. The patient recovered after occlusion of the fistula with a detachable balloon.

Fracture healing with osteopathy in traditional Mongolian medicine

OBJECTIVE: To explore the concept and norm of fracture healing with osteopathy in traditional Mongolian medicine (TMM). METHODS: Based on the correspondence between man and the universe (including psychosomatic integration) in fracture healing with osteopathy in TMM, we used modern physio-psychological and biomechanical principles and methods to probe the integrated, dynamic and functional characteristics of fracture healing. RESULTS: Based on the integration of limbs and the body, unification of the body and function and harmony of man and nature (including psychoso-matic integration), fracture healing with osteopathy in TMM comprises the concept of natural functional healing of fractures, and follows the norm of considering physiological healing and psychological function as well as limb healing and motor function. CONCLUSION: Fracture healing with osteopathy in TMM is characterized by a lack of trauma without future complications. This therapy makes the concept of fracture healing develop in the direction of humanity, behaviorism and integration.