National Institute of Traumatology & Orthopaedic Rehabilitation

The aim of this study was to investigate and compare the therapeutic effect of three different combinations in the conservative treatment of carpal tunnel syndrome (CTS) by means of clinical and electrophysiological studies. The combinations included tendon- and nerve-gliding exercises in combination with splinting, ultrasound treatment in combination with splinting and the combination of ultrasound, splinting, tendon- and nerve-gliding exercises. A total 28 female patients (56 wrists) with clinical and electrophysiologic evidence of bilateral CTS were studied. In all patient groups, the treatment combinations were significantly effective immediately and 8 weeks after the treatment. The results of the long-term patient satisfaction questionnaire revealed that symptomatic improvement is more prominent in the group treated with splinting, exercise and ultrasound therapy combination. Our results suggest that a combination of splinting, exercise and ultrasound therapy is a preferable and an efficacious conservative type of treatment in CTS.

The operative treatment of lesions of the anterior cruciate ligament (ACL) in athletes has been widely advocated and performed. We have investigated the outcome of non-operative management in a lower-demand, general population. We reviewed a consecutive group of 228 patients, which excluded professional and high-level athletes, for two to 12 years after an ACL lesion had been diagnosed by arthroscopy. There was a low incidence of secondary ACL and meniscal surgery, 5.4% and 3.5% respectively, and all these procedures were performed during the first three years after the ACL injury. We studied a subgroup of 109 patients with follow-up of at least five years (mean 8.5 years) and evaluated them using the IKDC score. The general outcome was reasonably satisfactory, with 23% in grade A, 50% in grade B, 21% in grade C and only 6.4% in grade D. We found no statistically significant prognostic effect within this group as regards age, activity levels, or the incidence of associated lesions.

A prospective in vivo assay was used to identify cells with potential for multiple lineage differentiation. With this assay, it was first determined that the 5-fluorouracil resistant cells capable of osseous tissue formation in vivo also migrated toward stromal derived factor-1 (SDF-1) in vitro. In parallel, an isolation method based on fluorescence-activated cell sorting was employed to identify a very small cell embryonic-like Lin-/Sca-1+CD45- cell that with as few as 500 cells was capable of forming bone-like structures in vivo. Differential marrow fractionation studies determined that the majority of the Lin-Sca-1+CD45- cells reside in the subendosteal regions of marrow. To determine whether these cells were capable of differentiating into multiple lineages, stromal cells harvested from Col2.3 Delta TK mice were implanted with a gelatin sponge into SCID mice to generate thymidine kinase sensitive ossicles. At 1.5 months, 2,000 green fluorescent protein (GFP)+ Lin-Sca-1+CD45- cells were injected into the ossicles. At harvest, colocalization of GFP-expressing cells with antibodies to the osteoblast-specific marker Runx-2 and the adipocyte marker PPAP gamma were observed. Based on the ability of the noncultured cells to differentiate into multiple mesenchymal lineages in vivo and the ability to generate osseous tissues at low density, we propose that this population fulfills many of the characteristics of mesenchymal stem cells.

Pulmonary injury resulting from inhalation of chemical and particulate products of incomplete combustion is one of the principal determinants of mortality following burn injury. In this study, the histopathology of inhalation injury was examined in sheep. Mild, moderate, or severe smoke injury was produced in anesthetized sheep by insufflation with various doses of ambient temperature smoke, generated by burning polyethylene, wood pulp, and nonwoven cellulose pads. A total of 64 sheep were exposed and evaluated at times ranging from 15 minutes to 4 weeks after exposure. Morphologic changes in the lungs were studied using light microscopy and both transmission and scanning electron microscopy. The primary, dose-responsive injury observed was acute cell membrane damage in the trachea and bronchi leading to edema, progressive necrotic tracheobronchitis with pseudomembrane formation, and airway obstruction. These inflammatory and occlusive effects were followed by congestion, alveolar space edema, atelectasis, and bronchopneumonia. Morphologic changes occurring in the alveolar epithelium following high smoke dosage included intracellular edema in type-I cells, changes in the membrane-bound vacuoles of type-II cells, and septal thickening caused by interstitial edema. No capillary endothelial changes were observed.

BACKGROUND: This study aimed to systemically review the effectiveness of aquatic exercise (AQE) compared to land-based exercise (LBE) in treating knee osteoarthritis (OA). METHODS: The Medline, Embase, Web of Science, Cochrane Central Register of Controlled Clinical Trials, CINAHL, and psyclNFO databases were comprehensively searched for randomized controlled trials (RCTs) evaluating the effectiveness of AQE and LBE for knee OA from their inception date to September 24, 2018. The risk of bias was examined using the Cochrane Collaboration Tool, and Review Manager 5.3 was used for data collation and analysis. RESULTS: Eight RCTs were included, involving a total of 579 patients. The meta-analysis showed that there was no significant difference between AQE and LBE for pain relief, physical function, and improvement in the quality of life, for both short- and long-term interventions, in patients with knee OA. However, the adherence and satisfaction level for AQE was higher than for LBE. Compared to no intervention, AQE showed a mild effect for elevating activities of daily living (standardized mean difference [SMD]: -0.55, 95% confidence interval [CI] [-0.94, -0.16], P = .005) and a high effect for improving sports and recreational activities (SMD: -1.03, 95% CI [-1.82, -0.25], P = .01). CONCLUSION: AQE is comparable to LBE for treating knee OA.

BACKGROUND: Tuberculosis (TB) of the spine is a common site of osseous TB, accounting for 50%-60% of cases. Spinal TB still occurs in both developed and developing countries. The diagnosis of spinal TB is difficult and it commonly presents at an advanced stage. Delays in establishing diagnosis and management result in complications such as spinal cord compression and spinal deformity. METHODS: A total of 582 patients with TB of the cervical, thoracic and lumbar spine with moderate to severe cord compression were studied. Variable degrees of neurological deficit with deformity were treated from January, 2003 to July, 2014. Thoracotomy along with anterolateral decompression and autogenous strut bone grafting with simultaneous fixation by screws and rods were performed in 113 cases. Posterior decompression, posterior interbody and posterolateral fusion by bone graft with stabilization by transpedicular screws and rods were done in the remaining 469 cases. Appropriate anti-TB drugs were given to all patients for 18-24 months. The follow-up period was 3 months to 10 years. RESULTS: The average age was 32.5 years. All patients survived surgery. There were 7 cases of superficial infections (1.2%) whilst there were 4 cases (0.7%) of deep infections. Revision surgery was performed in 6 patients (1.0%). Implant failure occurred in 4 cases (0.7%) whilst malposition of screws occurred in 12 cases (2.1%). Perioperative bleeding complications were reported for 4 patients (0.7%). Neurological improvement occurred in all patients except for 2 cases (0.3%). Preoperatively, the majority of patients (n=221, 38%) were classified with Class A on the American Spinal Injury Association (ASIS) neurological impairment scale. This was significantly reduced postoperatively to 0.4%. CONCLUSIONS: For patients with spinal TB anterior debridement, auto graft bone fusion, anterior or posterior fixation appears to be effective in arresting disease, correcting kyphotic deformity and maintaining correction until solid spinal fusion.

BACKGROUND: the scoliometer was developed to analyze the axial rotation of the trunk in patients with idiopathic scoliosis. However, there is controversy regarding the reliability of the measures obtained with this device. OBJECTIVES: to test the intra-rater and inter-rater reliability of the scoliometer in patients with scoliosis. METHODS: 24 volunteers of both sex with idiopathic scoliosis diagnostic (18 ± 4 years-old) and curvatures with mean and standard deviation of 24.8 ± 12.7º Cobb. The measurement procedure was accomplished in one day by two trained examiners. The palpation and determination of each spinal level was accomplished by just one examiner. Each examiner obtained one measure with the device for each vertebra from the thoracic and lumbar levels in each evaluation. For statistical analysis the measurements were divided by spinal levels into upper thorax, medium thorax, lower thorax and lumbar segments. The Intraclass Correlation Coefficient type 1,1 (ICC1,1) was used to determine the intra-rater reliability while the ICC3,1 was used to determine the inter-rater reliability. RESULTS: the observed intra-rater reliability values for the medium and lower thorax and lumbar segments of the subjects ranged from very good to excellent. The inter-rater reliability of the measures of axial trunk rotations was considered good to the upper thorax and excellent for the medium and lower thorax and lumbar spine. CONCLUSIONS: the scoliometer is a device that has intra-rater reliability estimates ranging from very good to excellent. The inter-rater reliability for the upper and low thorax and for the lumbar spine is relatively lower than the intra-rater values for the same spinal segments, even when the errors from palpation and positioning of the instrument were eliminated.

The articular disc of the distal radioulnar joint anatomy was studied in 109 wrist joints from 64 fresh adult cadavers. The disc is a strong fibrocartilaginous semicircular biconcave structure well adapted to its various functional roles. The length of the disc at its radial attachment varied between 12 and 20 mm (in most cases, 14-16 mm), and the width, measured between the apex and the radial base, varied from 7 to 14 mm, (in most cases, 9-11 mm). The thickness of the dorsal and palmar margins and the ulnar apex varied from 3 to 6 mm (in most cases, 4-5 mm), whereas the thickness of the central part varied from 0.5 to 3 mm (in most cases, 1 mm) and in a number of cases was perforated. Because the incidence of perforations increases progressively with the age of the subjects, the perforations were assumed to be degenerative in nature. Although the articular disc is a definable anatomic entity, it is intimately attached to surrounding elements to form a complex anatomic and functional structure.

OBJECTIVES: To determine the extent of all forms of tobacco usage in adult Bangladeshis in relation to gender and locality. METHODS: Three annual urban and rural cross-sectional surveys were carried out between 2001 and 2003 involving a total of 35,446 adults, of whom 54.3% were female and 51.0% were rural dwellers. Data were collected through interview using a structured questionnaire. RESULTS: The overall prevalences of smoking, chewing tobacco and gul usage were 20.5%, 20.6% and 1.8%, respectively. Current smoking and gul usage were significantly higher in males (42.2% and 2.2%, respectively) than females (2.3% and 1.5%, respectively) while chewing tobacco was more common in females (21.6%) than males (19.4%). No significant urban-rural difference was observed in smoking rate after adjusting for sociodemographic variables, while chewing tobacco was 1.5 times more likely to occur in rural residents and gul usage was 3.6 times more likely to occur in urban residents. On average a smoker consumed 9.3 sticks a day with males and rural residents smoking more. CONCLUSIONS: Nearly a third of the population in Bangladesh use some form of tobacco. There are marked urban-rural and male-female differences. This difference is mainly accounted for by the higher prevalence of chewing tobacco in rural areas, rural female tobacco usage is close to double than the urban rate. Smoking rates were low in Bangladeshi females, more so in urban than rural areas. The tobacco awareness programme in Bangladesh might require putting emphasis on smokeless tobacco as well as smoking.

AIM: To evaluate social media usage of orthopaedic patients to search for solutions to their health problems. METHODS: The study data were collected using face-to-face questionnaire with randomly selected 1890 patients aged over 18 years who had been admitted to the orthopaedic clinics in different cities and provinces across Turkey. The questionnaire consists of a total of 16 questions pertaining to internet and social media usage and demographics of patients, patients' choice of institution for treatment, patient complaints on admission, online hospital and physician ratings, communication between the patient and the physician and its effects. RESULTS: < 0.05). CONCLUSION: We concluded that patients have been increasingly using the internet and social media to select a specific physician or to seek solution to their health problems in an effective way. Even though the internet and social media offer beneficial effects for physicians or patients, there is still much obscurity regarding their harms and further studies are warranted for necessary arrangements to be made.

A clinical trial was conducted to evaluate the postoperative analgesic efficacy and the safety of intrathecal neostigmine in patients undergoing anterior and posterior vaginoplasty under spinal anaesthesia. Thirty-six patients were randomly divided into three groups to receive: normal saline (1 ml), morphine (100 micrograms in 1 ml of saline) or neostigmine (100 micrograms in 1 ml of saline) intrathecally just before a spinal injection of hyperbaric bupivacaine (0.5%, 4 ml). The mean [SD] time to the first analgesic (nonsteroidal anti-inflammatory drug) administration was significantly prolonged by intrathecal neostigmine (10.7 [4.3] h) and morphine (15.3 [3.0] h) compared with saline (4.5 [1.0] h). The three groups also differed in the number of patients requiring subcutaneous morphine to complement the analgesia provided by the intramuscular nonsteroidal anti-inflammatory drugs and the mean [SD] times for their administration: eight patients in the saline group (8.0 [3.8] h), one patient in the morphine group (18 h) and two patients in the neostigmine group (8 and 12.9 h). The morphine and neostigmine groups showed similar analgesic effectiveness. The characteristics of spinal anaesthesia were not modified by intrathecal morphine or neostigmine. Severe nausea and vomiting, sweating and distress during surgery were the most obvious adverse effects of intrathecal neostigmine. On the other hand, less hypotension was observed in the neostigmine group. The usefulness of intrathecal neostigmine as the sole postoperative analgesic may be restricted by the severity of its adverse effects.

To study the possible effects of diclofenac sodium on intestinal anastomoses, 48 rabbits were submitted to surgery consisting of two single-layer ileal anastomoses performed with separate propylene 5-0 sutures. The animals were divided at random into two groups (test and control). The animals in the test group were given intramuscular injections of diclofenac sodium at the dose of 3 mg/kg body weight at 24-hour intervals, and the control animals were given injections of an identical amount of 0.9 percent saline. The animals were sacrificed on the 3rd, 7th, and 14th postoperative days for macroscopic evaluation of the peritoneal cavity and of the anastomoses, tensile strength measurement, hydroxyproline determination, and histopathologic examination. The following results were observed: anastomotic dehiscence followed by peritonitis and death in five test animals (20.83 percent) and no control animals; decreased anastomotic tensile strength on the 7th day in test animals (P less than 0.05); delayed acute inflammatory response and onset of fibroblast proliferation in the test group; and similar hydroxyproline levels in both groups. On the basis of the results obtained, we conclude that diclofenac sodium had a negative effect on intestinal anastomotic healing.

We examined 1020 dry clavicles from cadavers of Italian origin to determine the prevalence of the coracoclavicular joint (ccj), a diarthrotic synovial joint occasionally present between the conoid tubercle of the clavicle and the superior surface of the horizontal part of the coracoid process. Five hundred and nine clavicles from individuals of different ages were submitted to X-ray examination. Using radiography, we measured the entire length and the index of sinuosity of the anterior lateral curve, on which the distance between the conoid tubercle and the coracoid process depends. We also used radiography to record the differences in prevalence of arthritis in two neighbouring joints, the acromioclavicular and sternoclavicular joints. Of the 1020 clavicles, eight (0.8%) displayed the articular facet of the ccj. No statistical correlation was found between clavicular length and the index of sinuosity of the anterior lateral curve. The prevalence of arthritis in clavicles with ccj was higher than that revealed in clavicles without ccj. The prevalence of ccj in the studied clavicles is lower than that observed in Asian cohorts. Furthermore, ccj is not conditioned by either length or sinuosity of the anterior lateral curve of the clavicle. Finally, the assumption that ccj is a predisposing factor for degenerative changes of neighbouring joints is statistically justified.

BACKGROUND: Several forms of conservative treatment have been the focus of many recent studies in knee osteoarthritis (OA). Among these techniques, the application of pulsed shortwave (PSW) treatment has been widely used, but the optimal dose and application time have not been well established. Objective The purposes of this study were: (1) evaluate the effect of PSW treatment in different doses and (2) to compare low-dose and high-dose PSW groups with control and placebo groups. Design This was a randomized clinical trial. Setting The study was conducted in the physical therapy department of 2 large urban hospitals. Patients One hundred twenty-one women (mean age=60 years, SD=9) with a diagnosis of knee OA participated in the study. INTERVENTION AND MEASUREMENTS: Participants were distributed randomly into 4 groups: 35 participants did not receive any treatment (control group), 23 received a placebo treatment, 32 received low-dose PSW treatment (power of 14.5 W, treatment duration of 19 minutes, and total energy of 17 kJ), and 31 received high-dose PSW treatment (power of 14.5 W, treatment duration of 38 minutes, and total energy of 33 kJ). An 11-point numerical pain rating scale and the Knee Osteoarthritis Outcome Score were used to assess pain and function in 3 stages: at initial evaluation (pretreatment), immediately after treatment, and at 12-month follow-up. RESULTS: The 4 groups were homogeneous prior to treatment with respect to demographics, pain, and functional scale data. The results demonstrated the short-term effectiveness of the PSW at low and high doses in patients with knee OA. Both treatment groups showed a significant reduction in pain and improvement in function compared with the control and placebo groups (effect size: range=20.0-23.4 for the low-dose PSW group and range=15.7-16.5 for the high-dose PSW group). There were no differences in results between PSW doses, although a low dose of PSW appeared to be more effective in the long term. Limitations These results were achieved without physical exercise, which could have positively influenced the results. CONCLUSIONS: Pulsed shortwave treatment is an effective method for pain relief and improvement of function and quality of life in the short term in women with knee OA. On the basis of the results, application of PSW treatment is recommended in the female population with knee OA. However, conclusions regarding the 12-month follow-up should be analyzed carefully due to the high dropout rate.

Abstract At the beginning of 2020, COVID-19 became a global problem. Despite all the efforts to emphasize the relevance of preventive measures, not everyone adhered to them. Thus, learning more about the characteristics determining attitudinal and behavioral responses to the pandemic is crucial to improving future interventions. In this study, we applied machine learning on the multi-national data collected by the International Collaboration on the Social and Moral Psychology of COVID-19 (N = 51,404) to test the predictive efficacy of constructs from social, moral, cognitive, and personality psychology, as well as socio-demographic factors, in the attitudinal and behavioral responses to the pandemic. The results point to several valuable insights. Internalized moral identity provided the most consistent predictive contribution—individuals perceiving moral traits as central to their self-concept reported higher adherence to preventive measures. Similar was found for morality as cooperation, symbolized moral identity, self-control, open-mindedness, collective narcissism, while the inverse relationship was evident for the endorsement of conspiracy theories. However, we also found a non-negligible variability in the explained variance and predictive contributions with respect to macro-level factors such as the pandemic stage or cultural region. Overall, the results underscore the importance of morality-related and contextual factors in understanding adherence to public health recommendations during the pandemic.

Fifteen nosocomial cases of extended-spectrum beta-lactamase-producing Klebsiella pneumoniae occurred among 132 neonates in a premature intensive care unit in Hungary in June through November 1998. Fourteen strains were indistinguishable by molecular biological typing and harbored the same single conjugative extended-spectrum beta-lactamase-encoding plasmid that was spontaneously found in a Serratia marcescens strain in the same patient.

Rheumatoid arthritis (RA) and osteoarthritis (OA) are chronic diseases associated with morphological joint changes. Synovial membrane (SM) involvement was established for RA, but the data for OA are limited, because OA is usually regarded as noninflammatory disease. Changes in immune system in RA are not limited to joints, and the significant role of T cells of peripheral blood (PB) is not disputable. However, there is still an open debate about PB immunological profile in OA. Therefore, we decided to measure the distribution of CD4+ and CD8+ T cells, regarding CD28 expression, both in PB and SM of RA and OA patients, on the same day. Altogether, eleven RA patients, 11 OA patients and similar numbers of age-matched healthy controls were included into the study. Flow cytometry was used for T cells subpopulation distinguishing and quantification; monoclonal antibodies against CD3, CD4, CD8 and CD28 with different fluorochromes were used for stainings. The RA patients had significantly higher percentage of CD3+4+ cells in PB as compared to OA patients and relevant control group. Both within the CD4+ and CD8+ compartments, significantly lower percentages of cells bearing the CD28 marker were found in the PB of OA as compared to RA patients. The proportion of CD3+CD4+ cells in SM was dependent on age of OA patients, older OA patients had significantly higher value of their SM/blood ratio than RA patients. Older OA subjects were also characterized by higher values of the SM/blood ratio of both CD4+CD28+ and CD8+CD28+ subpopulations than RA or younger OA patients. In conclusion, in contrast to the traditional view of OA disease, our results give support to the hypothesis that OA may also (like RA) be a disease with a local immunological involvement.

BACKGROUND AND PURPOSE: An increased incidence rate of acromioplasty has been reported; we analyzed data from the Finnish National Hospital Discharge Register. PATIENTS AND METHODS: During the 14-year study period (1998-2011), 68,877 acromioplasties without rotator cuff repair were performed on subjects aged 18 years or older. RESULTS: The incidence of acromioplasty increased by 117% from 75 to 163 per 10(5) person years between 1998 and 2007. The highest incidence was observed in 2007, after which the incidence rate decreased by 20% to 131 per 10(5) person years in 2011. The incidence declined even more at non-profit public hospitals from 2007 to 2011. In contrast, it continued to rise at profit-based private orthopedic clinics. INTERPRETATION: We propose that this change in clinical practice is due to accumulating high-quality scientific evidence that shows no difference in outcome between acromioplasty and non-surgical interventions for rotator cuff disease with subacromial impingement syndrome. However, the exact cause of the declining incidence cannot be defined based solely on a registry study. Interestingly, this change was not observed at private clinics, where the number of operations increased steadily from 2007 to 2011.

OBJECTIVE: The purposes of this study were to describe the early signs and symptoms of osteosarcoma and Ewing's sarcoma, identify symptoms that could be used to help differentiate the two types of tumors, and determine the time elapsed between the onset of signs and symptoms and the definitive diagnosis in our service, providing information and imputus for earlier diagnosis of these tumors. METHODS: A retrospective analysis of the medical dossiers of 365 patients under 30 years of age diagnosed with osteosarcoma or Ewing's sarcoma was performed, and the aspects of the clinical diagnosis were statistically analyzed and compared. RESULTS: The time between the onset of signs and the symptoms was 5.25 months for osteosarcoma and 8.1 months for Ewing's sarcoma, and the most frequent (89.5%) early symptom of osteosarcoma and Ewing's sarcoma was local pain. Symptoms that might aid diagnosis included early local volume increase and the presence of fever. CONCLUSION: The time until diagnosis of both neoplasias was higher than that reported for North America and Europe. Education of the lay public and medical professionals regarding suspicious early signs and symptoms might shorten the delay of diagnosis.

Two Dhaka, Bangladesh, landfills are explored to understand how management practices impact environmental quality and public health in the surrounding areas. A combination of research methods is used, such as geospatial buffer zone analysis, semi-structured observation checklist and qualitative interviews, to gain an understanding of the waste transportation, leachate percolation, and adverse health and environmental effects. A multi-ring buffer zone and ground truth method were applied through ArcMap for the spatial distribution of landfill-adjacent environmental features. Qualitative interviews were conducted with landfill officials and nearby residents. Findings reveal that landfills are situated very close to residential areas, water bodies and agricultural lands, exposing them to various health and environmental hazards. Improper solid waste management practices of the landfills cause adverse environmental effects by leachate percolation, waste incineration and vector breeding. Adjacent dwellers suffer from bronchial diseases, pneumonia, diarrhoea, itching problems, headache and appetite loss. The existing solid waste management system requires managerial and technical modifications to reduce the associated environmental pollution and health hazards. <em><strong>Practice relevance</strong></em> Waste management practices impact directly on environmental and public health. Dhaka’s existing waste management practices can become better organised to address these concerns. Source waste reduction must be implemented to ensure the reduction of disposed waste at landfills. Administrative capacity of landfills requires improvement to ensure proper waste management procedures. Increased awareness is also needed among the general population and waste handlers about the adverse effects of uncontrolled waste dumping, along with enforcement measures for improper waste practices. Application of a low-tech, simple and innovative method to improve the leachate treatment process is also needed. Environmentally friendly treatments should be considered in order to minimise landfill odour. Regular training programmes and monitoring activities are needed to ensure the proper utilisation of comfortable and convenient safety gear and reduce vector breeding.