Early Motion Exercises Research Articles

大腿骨遠位端骨折の治療経験

Fractures of the distal femur were studied in twenty patients treated at Hamanomachi General Hospital, consisting of eight males and twelve females with a mean age of 59.3 years (range, 13 to 83 years). The average duration of follow-up study was 1.5 years (range; 0.4 to 9.5 years). All patients were classified according to the AO/ASIF classification and Kuwano's criteria was used for the assessment of the results.There were twelve cases of type A, three of type B, and five of type C.Type A: Closed treatment consisting of skeletal traction or a plaster cast was performed on four patients. Internal fixation was used in eight patients: Kirschner wires (K-wire) in one, Zickel nail in five, Intramedullary Supracondylar nail (IMSC nail) in one, and May anatomical bone plate in one. Results were excellent in six, good in four, and fair in two. Perfect anatomical reduction was not necessary, while correction of the axial alignment, length and rotation were necessary. Closed treatment or intramedullary fixation is thought to be preferable.Type B: Open reduction and internal fixation were performed on all patients using K-wire, Herbert screw or cannulated screw with good to excellent results. An accurate anatomical reduction of the joint surface and early motion exercise is essential.Type C: Internal fixation was performed in four patients: K-wire or Tibia bolts in three, and IMSC nail in one with excellent results. Closed treatment was done on one patient who had hemophilic arthropathy with fair result. Open anatomical reduction of the joint surface and internal fixation are thought to be preferable. And early motion exercise is necessary.We conclude that selecting the appropriate treatment for each case is important.

FIXATION OF METACARPAL FRACTURES USING ABSORBABLE HEMI-CERCLAGE SUTURES

We retrospectively reviewed the use of biodegradable hemi-cerclage sutures in the treatment of 79 metacarpal fractures in 66 patients. The polyglycolic acid hemi-cerclages achieved sufficient fracture fixation to permit early motion exercises, but fractures were also immobilized for a mean of 3.7 (range, 1.5–6) weeks postoperatively, during which time physiotherapy was given. Adequate bony stability was achieved after a mean of 4.5 (range, 3.5–7) weeks and fracture redisplacement occurred in only one case.

肩けん板断裂の手術成績 術後早期他動運動を行った症例

54 shoulder rotator cuff repairs that were rehabilitated by early passive motion exercise were followed up after at least one year post-operatively, and evaluated with the JOA shoulder scoring system. The mean JOA shoulder score improved from 67.4 to 93.4 post operatively. 34 (63%) scored over 95 points, 8 (15%) were less than 95 to 90 points, 8 were less than 90 to 80 points and 4 were less than 80 points, Small cuff tear showed relative low JOA shoulder score (86.7 points) post operatively, due to post operative pain and limited ROM. Though 8 shoulders had weak shoulder external rotation power, threr were no evidence of rupture during early motion exercise. In recent series of 21 shoulders, 17 showed early functional recover.

COMPARTMENT SYNDROMES IN OBTUNDED PATIENTS

A high index of suspicion for a compartment syndrome in the upper extremity should be maintained in all obtunded patients who are at risk for the condition. Obtunded patients are those with a dulled or altered physical or mental status secondary to injury, illness, or anesthesia; those with diminished or absent sensation in the upper extremity because of nerve injury or anesthesia; and those whose ability to communicate is impeded, such as infants and young children and the mentally ill or disabled. These patients represent a vulnerable group whose inability to demonstrate the hallmark symptoms and signs of the syndrome puts them in jeopardy of a late diagnosis of a compartment syndrome and its potentially devastating sequelae. The most likely causes of a compartment syndrome in this population are skeletal or soft-tissue trauma, prolonged limb compression, thrombolytic therapy after myocardial infarction, arterial or intravenous fluid administration, and upper extremity Surgery. Whenever a compartment syndrome of the hand, forearm, or upper arm is suspected, the obtunded patient should be examined closely and frequently, and any changes over time should be documented carefully. Intracompartmental pressure measurement provides a useful adjunct to the physical examination and history in these patients and may be diagnostic if other symptoms and signs are obscured. Once the compartment syndrome is diagnosed, emergent fasciotomy is indicated. To avoid a loss of function in the obtunded patient, special care must be taken postoperatively to assure that early motion exercises are carried out.

Ankle ligament injuries

Acute ankle ligament sprains are common injuries. The majority of these occur during athletic participation in the 15 to 35 year age range. Despite the frequency of the injury, diagnostic and treatment protocols have varied greatly. Lateral ligament complex injuries are by far the most common of the ankle sprains. Lateral ligament injuries typically occur during plantar flexion and inversion, which is the position of maximum stress on the anterotalofibular liagment (ATFL). For this reason, the ATFL is the most commonly torn ligament during an inversion injury. In more severe inversion injuries the calcaneofibular (CFL), posterotalofibular (PTFL) and subtalar ligament can also be injured. Most acute lateral ankle ligament injuries recover quickly with nonoperative management. The treatment program, called "functional treatment," includes application of the RICE principle (rest, ice, compression, and elevation) immediately after the injury, a short period of immobilization and protection with an elastic or inelastic tape or bandage, and early motion exercises followed by early weight bearing and neuromuscular ankle training. Proprioceptive training with a tilt board is commenced as soon as possible, usually after 3 to 4 weeks. The purpose is to improve the balance and neuromuscular control of the ankle. Sequelae after ankle ligament injuries are very common. As much as 10% to 30% of patients with a lateral ligament injury may have chronic symptoms. Symptoms usually include persistent synovitis or tendinitis, ankle stiffness, swelling, and pain, muscle weakness, and frequent giving-way. A well designed physical therapy program with peroneal strengthening and proprioceptive training, along with bracing and/or taping can alleviate instability problems in most patients. For cases of chronic instability that are refractory to bracing and external support, surgical treatment can be explored. If the chronic instability is associated with subtalar instability that is refractory to conservative measures and bracing as outlined above, surgical treatment must address the subtalar joint as well. Subtalar ligament injury and instability are probably more common than appreciated. Definition and diagnosis of this entity are difficult, however. Fortunately, it appears that in the majority of the acute injuries healing occurs with the same functional rehabilitation program as that for lateral ankle ligament sprains. For chronic subtalar instability an intial attempt at functional rehabilitation with ankle proprioceptive training and bracing should be attempted. If this program fails primary repair or reconstruction can be beneficial. Reconstructive procedures must address the subtalar joint. Subtalar instability often occurs in conjunction with talocrural instability, so careful diagnosis is critical in anyone with chronic ankle instability. If either is not addressed, the patient will continue to have problems. Deltoid ligament injuries most often occur in association with ankle fractures. They are rare as isolated injuries. If no fracture is evident on radiographs, particular attention must be paid to the syndesmosis to ensure there is not an associated syndesmosis disruption. True isolated deltoid injuries seem to do well with non-operative functional treatment as for lateral ankle ligament injuries. Deltoid ruptures associated with ankle fractures appear to heal well by addressing the other injuries and allowing the deltoid to heal on its own. It is vital to correct any syndesmosis injury and to obtain correct bony alignment. Syndesmosis injuries can be debilitating if not treated properly. Careful physical exam and interpretation of radiographs is necessary to obtain a correct diagnosis. Partial injuries appear to do well with functional rehabilitation. However, complete tears, if widening is not corrected, can lead to chronic ankle pain and early degenerative changes. Widening of the syndesmosis with a tear of the inferior tibiofibular ligaments is an indication for surgery to place a syndesmosis screw for reduction of the mortise. Protected weight bearing is required for about 6 weeks after surgery, at which time the screw should be removed. A functional rehabilitation program can then begin.

Surgical treatment for pilon fracture of the ankle-open reduction and internal fixation.

From 1991 to 1994, 39 ankles of 38 patients underwent surgical open reduction and internal fixation for pilon fractures. These patients included 29 males and 9 females with an average age of 38.6 y/o (range 28 y/o-58 y/o). The follow up and evaluation period averaged 31.7 months (range 22Ms-44Ms), during which time a standing x-ray for arthrosis grading and functional scale was used for clinical evaluation. Complications included 1 case of infection, 1 case of loss reduction, 2 cases of partial skin necrosis and 2 cases of delayed union. Post-traumatic arthritis occurred in 23 ankles (59%) but only 4 ankles of grade 4 arthrosis resulted in poor functional scale and the overall satisfactory rate was 82%. It was found that anatomic reduction, rigid fixation and early motion exercise are important to successful treatment of ankle fractures. Regarding pilon fracture, specifically the severity of fracture pattern and delay of reduction are important problems to overcome to ensure successful results. Therefore, adequate surgical approach for entire view of ankle joint, reduction and fixation of fibula, sufficient bone graft for articular support, intraoperative x-ray check and postoperative immobilization are essential for the achievement of better clinical results.

Results of non-operative treatment with Kyuro brace therapy for acute anterior cruciate ligament tears

A non-operative treatment employing a knee brace with early-motion exercise was performed on 58 of 90 consecutive patients with acutely torn anterior cruciate ligaments. Of those 58 patients 34 showed healing under second-look arthroscopy at 3 months after injury. Detachment type tears showed a significantly higher healing rate ( P < 0.03) and less instability on stress views ( P < 0.03) than mop-end type tears at follow-up (mean: 3.7 years). Instabilities of injury correlated significantly with those at follow-up on stress views ( P < 0.01). Three patients had sustained a retear during chronic phase. This method can be considered appropriate for detachment type tears without a severe instability.

Open reduction and internal fixation of the calcaneus using minifragment plates.

During a 4-year period, 35 nonconsecutive intraarticular fractures of the calcaneus were fixed with 2.7-mm minifragment plates and 3.5-mm small fragment screws through an extended lateral approach. There were 25 type II and 10 type III fractures by the classification system of Sanders. The reduction of the facet was anatomic in 91%. The reduction of the tuberosity was acceptable (< or = 5 degrees of angulation) in all cases. Early motion was begun in the ankle, subtalar, and midfoot joints in all cases. Two patients had minor edge necrosis amenable to local treatment. There were no deep infections. Using the Maryland foot score, there were 77% good or excellent results. The small size of the minifragment plates allows for their application to a wide variety of fracture patterns. They are also low profile and are therefore easy to cover. Multiple plates were used in many cases without steric interference. They provided rigid enough fixation to allow aggressive early motion exercises without loss of reduction or hardware failure in any case. Minifragment plates with small fragment screws are effective for the fixation of intraarticular calcaneus fractures through an extended lateral approach.

Treatment of tibial fractures by interlocking intramedullary nailing

The adequate treatment of tibia fracture is one of the most difficult due to severe commiuntion, open wound, delayed union, angulation deformity and infection. We treated 38 fractures of the tibia by Interlocking intramedullary nail from Feb. 1983 to Mar. 1993, 35 cases of the tibia fracture were fresh, 13 cases of fracture were open. The other 3 cases were delayed union and nonunion. The Mean follow-up was 14.0 months. The results were as followings. 1. Of the 38 fractures, 37 fractures united and the mean union time was 18.7 weeks. 2. Interlocking intramedullary nail could be used to the majority of fractures of the proximal & distal tibia shaft fractures. 3. The Interlocking nail had rigid rotational stability and was appropriate for the treatment in severe unstable fractures, commninution and open with bone loss. 4. Delayed union or nonunion was a good indication for intramedullary nailling. 5. The major complication were valgus deformity of 2 cases, varus deformity of 1 case, 1 case deep infection. 6. Interlocking intramedullary nailing provided rigid fixation of fracture and then made early joint motion exercise and ambulation.