Postoperative Mobilization Research Articles

Biomechanical Evaluation of a Tubular Braided Construct for Primary Deep Flexor Tendon Surgery

Immediate postoperative mobilization has been shown to avoid adhesion formation and improve range of motion after flexor tendon repair. A tubular braided construct was designed to allow for these rehabilitation protocols. In this exvivo study, 92 ovine flexor tendons were divided randomly into 2 equal groups. After creating a transection, the tendons of the first group were repaired using a tubular braided construct. This construct, consisting of a tubular braid of polypropylene and polyethylene terephthalate fibers, exerts a grasping effect on the tendon ends. The control group received a multistrand modified Kessler repair with a looped polydioxanone suture (PDS) 4-0 suture and a Silfverskiöld epitendinous repair using an Ethilon 6-0 suture. After the repair, a static and an incremental cyclic tensile test was performed until failure. During the static test, the tubular braid resulted in a significantly higher load at 3 mm gap formation (86.3 N ± 6.0 vs 50.1 N ± 11.6), a higher ultimate load at failure (98.3 N ± 12.7 vs 63 N ± 11.1), higher stress at ultimate load (11.8 MPa ± 1.2 vs 8.1 MPa ± 3.1), and higher stiffness (7.1 N/mm ± 2.9 vs 8.7 N/mm ± 2.2). For the cyclic tests, survival analyses for 1-, 2- and 3-mm gap formation and failure demonstrated significant differences in favor of the tubular braided construct. The tubular braided construct withstands the required loads for immediate rehabilitation not only in static tests, but also during cyclic tests. This is in contrast with the control group, where sufficient strength is reached during static tests, but failures occur below the required loads during cyclic testing. The tubular braided construct provides a larger safety margin for immediate intensive rehabilitation protocols.

Causes for Unplanned Readmission to the Intensive Care Unit among Patients Receiving Intestinal Surgery

<p>目的：分析消化道手術重症病人非預期重返加護病房在病人本身、加護病房轉出前及轉出後之成因。</p> <p>材料與方法：研究收集南部某準醫學中心外科加護病房於2018至2019年接受消化道手術後入住外科加護病房重症病人之個人及住院過程相關資訊，進行統計分析。</p> <p>結果：共收集545位病人，其中有42位發生非預期重返加護病房事件。轉出至普通病房後，格拉斯哥昏迷指數(Glasgow Coma Scale, GCS)≦14分、使用高流量氧氣設備、呼吸道清除功能失效、無法早期活動及無家屬陪病的病人有較高的比例發生非預期性重返事件。</p> <p>結論：消化道手術重症病人轉出加護病房後，須注意意識、呼吸、活動狀態及家屬照護功能，有助於降低非預期重返加護病房的比例。</p> <p> </p><p>Objective: Analyzing causes for the unplanned readmission to the intensive care unit (ICU) in critically-ill patients receiving gastrointestinal surgery, and categorizing the causes into ones that lie in the patients themselves, events before being discharged from the ICU, and events after being discharged from the ICU.</p> <p>Materials and Methods: The demographic and hospitalization-related data of patients in the surgical ICU of a medical center in southern Taiwan between 2018 and 2019 were collected for statistical analysis. The inclusion criterium was patients who were readmitted into the ICU after receiving gastrointestinal surgery.</p> <p>Results: The data of 545 patients were collected. Among these patients, 42 experienced unplanned readmission to the ICU. After being transferred from the ICU into general wards, patients who had a Glasgow Coma Scale score of ≤ 14, required the use of high-flow oxygen devices, developed ineffective airway clearance, were incapable of early postoperative mobilization, and lacked family accompaniment were found to experience unplanned readmission to the ICU in a relatively higher percentage.</p> <p>Conclusion: To reduce unplanned readmission to the ICU, after critically-ill patients receiving gastrointestinal surgery are transferred from ICUs to general wards, medical personnel shall pay attention to the patients’ consciousness, breath, mobility, and family accompaniment.</p> <p> </p>

Use of a Multi-Sensor Monitoring Device in an Early Post-operative Mobilization Program.

The current study aimed to evaluate the validity and feasibility of using a multi-sensor device to monitor patient mobility in a large postoperative population. In this IRB-approved study, postoperative patient posture was recorded using a multi-sensor monitoring device (ViSi Mobile®) and compared with direct observations of patient physical activity. Retrospective cohort analysis of postoperative patient posture data from January to December 2019 was then performed. Patterns of postoperative mobilization were evaluated. Multi-sensor real-time posture monitoring with the ViSi Mobile® system consistently differentiate between rest and upright posture (sensitivity and specificity, both 100%). During observation of ambulatory events, ViSi Mobile® system correctly recorded a patient's position as upright at each validation time point in 72.7% (8 of 11) of walks. Clinical data from 562 postoperative patients were linked with posture monitoring data. Median duration of posture monitoring was 64hours (IQR 52.5) and median number of posture positions recorded per patient was 15,370 (IQR 12,685). Median duration of upright position per day was 148.6minutes (IQR 192.8). Duration in active upright position per day was not associated with risk of readmission (P > .05). Real-time posture data from a multi-sensor monitoring device (ViSi Mobile®) was shown to consistently differentiate rest and active upright position. This novel technology can provide useful insight into adherence and clinical benefit of early mobilization programs.

Perioperative Medicine: Managing for Outcome, 2nd Edition

Perioperative Medicine: Managing for Outcome, 2nd Edition

Combined Lung-Liver Transplantation Can Be Safely Performed in Patients with Hypokalemic Periodic Paralysis

<h3>Introduction</h3> Combined lung-liver transplantation (CLLT) is rare and accounts for <0.01% of multiorgan transplants performed. Due to its infrequency, the criteria for CLLT candidacy have not been clearly elucidated. However, since post-transplant rehabilitation is critical for a successful outcome, any condition that may compromise a patient's postoperative mobility is considered a potential contraindication to transplantation. We report our experience with CLLT in a patient who had hypokalemic periodic paralysis (HPP), a rare genetic disorder that affects muscle ion channels and manifests as hypokalemia with episodes of severe weakness or paralysis. To our knowledge, we present the first reported case of transplantation in a HPP patient. <h3>Case Report</h3> The patient was a 63-year-old male with 7-year history of idiopathic pulmonary fibrosis and cryptogenic cirrhosis. Other comorbidities included HPP since childhood. His HPP exacerbations, which manifested as weakness without respiratory symptoms, were precipitated by various medications and were treated with correction of hypokalemia. He was previously declined for CLLT by 9 other programs due to his age and HPP, but our multidisciplinary team determined that the patient's HPP could be adequately managed and should not preclude him from CLLT. While hospitalized for progressive respiratory failure, donor organs became available. Bilateral lungs and a liver were recovered from a brain-dead donor. Bilateral lung transplantation was performed followed by orthotopic liver transplantation. There were no intraoperative complications. Standard post-transplant care was initiated after surgery. He was transferred out of the ICU on postoperative day (POD) #5, and was discharged to home on POD #22. The patient's postoperative hospitalization was complicated by antibody-mediated rejection (AMR) from <i>de novo</i> donor-specific antibodies. His AMR was adequately managed with methylprednisone, plasmapheresis, and intravenous immunoglobulins. Meticulously maintaining serum potassium levels above 4 mEq/L and avoiding precipitating medications sufficiently prevented any HPP exacerbations. The patient has been home for 8 months and has been doing well. <h3>Summary</h3> The limits on candidacy for CLLT have not been clearly defined, but we demonstrated for the first time that CLLT can be safely performed in patients with HPP.

Risk factors affecting the inability to regain pre-fracture mobility after hip fracture surgery in elderly patients

Background: To evaluate the functional recovery at six months postoperatively in elderly patients with hip fractures and to determine the risks of not regaining to the pre-fracture mobility level.Materials and Method: In this retrospective observational cohort study, 281 patients over the age of 65 who underwent surgery for hip fracture were included in the study. The patients were divided into two groups (mobil without an aid and mobil with an aid) according to their pre-fracture level of mobility, and three groups according to their postoperative 6th month mobility level (mobil without an aid, mobil with an aid and immobile). In addition, motor-Functional Independence Measure (mFIM) scores were calculated to evaluate activities of daily living (ADL). Risk factors for not regain pre-fracture mobility and worsening of ADL were identified.Results: The rate of patients who could not regain their pre-fracture ADL after 6 months postoperatively was 34.1%. Patients with intertrochanteric fractures or those with an intraoperative proximal femoral nail (PFN) implanted were less likely to regain their pre-fracture mobility and ADL (p=0.006, p=0.005, respectively). The most important risk factors for not regain to pre-fracture mobility and worsening of ADL were advanced age, high ASA score, cardiovascular disease or malignancy among comorbidities, intertrochanteric fracture as fracture type, and PFN use as implant type.Conclusion: Advanced age, high ASA score, cardiovascular disease or malignancy among comorbidities, intertrochanteric fracture as fracture type, and use of PFN as implant type were the main risk factors for not regaining to pre-fracture mobility and ADL.

Predictors of mortality and length of stay after hip fractures – A multicenter retrospective analysis

BackgroundThe ubiquity of hip fractures pose a substantial burden on public health services worldwide. There is widespread geographical variation in mortality rates and length of stay after hip fractures. The current study investigates both the predictors of; (1) one-year mortality and (2) length of hospital stay (LOS) in adults aged 60 years or older. We aim to identify the risk factors and quantify the extent of influence they have on both outcomes. MethodologyA retrospective multi-center cohort study identified consecutively documented hip fractures between January 2013 and September 2018. A multivariate regression analysis of 603 patients was performed to determine independent factors affecting mortality and total LOS. ResultsThe study sample included 603 patients with a total one-year mortality rate of 20.6% (n = 124). Predictors of mortality included; longer LOS, increasing age, inability to return to baseline mobility and comorbid burden. The mean overall LOS was 15.1 days, and 22.6 days in the mortality group. Predictors of increased LOS included; previous hip fractures, comorbid burden; diabetic, cerebrovascular disease and smokers. Return to baseline mobility status was associated with reduced LOS. ConclusionPatients with a longer length of stay, inability to return to baseline mobility status, higher ASA scores, previous hip fractures and longer time to surgery had a higher mortality rate. Determinants of a longer LOS include; increased time to surgery, impeded postoperative mobility status, fixation rather than joint replacement and comorbid burden. A multifaceted approach to preoperative optimization and postoperative recovery is crucial in order to address all possible modifiable factors.

PREVENTION OF DEEP VENOUS THROMBOSIS IN POST-OPERATIVE ARTHROPLASTY PATIENTS WITHOUT USE OF ANTICOAGULANT THERAPY

Background: Deep vein thrombosis (DVT) is one of the most common complications of total hip (THA) and total knee arthroplasty (TKA), mostly due to immobilisation and to some extent due to pre-existing co-morbidities along with genetic predisposition. Though the reported incidence of DVT is very high in multiple studies, fatal thromboembolism is very rarely seen in clinical setup. Hence the issue of prophylaxis for DVT remains highly debated1. The incidence of DVT is largely based on various studies in European and American populations. Asian population is genetically and socially quite different from American and European populations, so the incidence of DVT can be quite different2. We conducted a retrospective study at our centre to determine incidence of DVT after THA and TKA in Indian patients. Methods: A retrospective study was conducted on in 45 patients and who underwent THA and TKA respectively, without any known risk factors for thromboembolic disease. No prophylaxis was given to the patients. The patients were monitored in the post op period for any signs and symptoms of DVT along with starting of adequate physiotherapy Results: DVT was found in one patient who had undergone THA, which was confirmed on colour Doppler ultrasonography of the affected limb. No case of DVT was detected in any patient who had undergone TKA. Conclusion: These results suggest that the incidence of DVT in patients is very low and is not comparable when adequate postoperative mobilisation and physiotherapy was done.We conclude that advising prophylactic anticoagulant therapy to these patients in the post op period could be successfully substituted by a simple and cost effective but adequate physiotherapy prevent DVT, in the process also bypassing the side effects of the anticoagulant therapy.

Basic principles of anesthesia and postoperative analgesia in patients operated within an enhanced recovery after surgery (ERAS) protocol

The Enhanced Recovery After Surgery (ERAS) system is a collection of preoperative, intraoperative, and early postoperative measures. The primary goal of gynecological surgery is a rapid and uneventful recovery from oncological and standard procedures, particularly in patients over the age of 65. The goal is to achieve comparable results to those obtained with minimally invasive procedures. Certain features of the ERAS system are similar to those of standard surgical procedures. These are the measures taken to prevent thromboembolism and to promote early postoperative mobility. Anesthesia and postoperative analgesia are critical components of achieving the ERAS system's objectives. The ERAS protocol requires multimodal non-opioid postoperative analgesia, infiltration of the surgical wound with a local anesthetic, and avoidance of opioid analgesics. We discuss current data on patient management according to the ERAS protocol for anesthesia and analgesia in order to minimize the body's stress reactions, promote early mobility, and reduce postoperative complications. ERAS protocol has gained popularity in recent years in a number of centers, primarily in the United States and Europe, due to its direct impact on hospital stay length, healthcare costs, and benefits for patients, their relatives, and caregivers. Keywords: ERAS protocol; multimodal opioid-sparing analgesia; local infiltration anesthesia.

69 Early Post-operative Mobilization After Treatment of Burn Wounds with Autologous Skin Cell Suspension

IntroductionEarly mobilization has become popular in the literature and the benefits in critically ill patients are well-documented. However, early mobilization in burn care is undefined. Clinical practice guidelines regarding post-operative mobilization (POM) of patients with burn injury, especially after autografting, are limited, resulting in significant practice variance among burn centers. Furthermore, data on mobilization after treatment with autologous skin cell suspension (ASCS), is even more limited, and wider practice variation exists. We hypothesize early POM is safe and does not compromise healing or lead to graft loss.MethodsA retrospective chart review was performed to examine mobility interventions utilized for patients, with mixed partial and full thickness burns, who received ASCS with polylactic acid sheet, with or without meshed splint-thickness skin grafting (STSG), over 6 months. Data included demographics, operative procedure, dressing, post-operative restrictions, POM date by burn therapy, and presence of graft loss ( >25% of grafted area with need for regrafting). The data was analyzed to corelate POM day and graft success. Initially, the authors utilized manufacturer splinting guidelines before becoming more judicious with aggressive early mobilization. Patients at risk of noncompliance and graft sheer were splinted.ResultsFifteen patients were included in the study. In those patients, 25 body areas were grafted with 17 areas receiving ASCS with polylactic acid sheet and 8 areas additionally receiving STSG. On post-operative day (POD) 0, four areas were splinted and no range of motion (ROM) was performed at the joint. The authors splinted 3 out of 4 patients (75%) due to initial manufacturer splinting guidelines. The 4th patient was splinted due to compliance concerns. For the other 21 areas, active ROM, functional mobility and performance of activities of daily living with functional movement was allowed on POD 0. A burn therapist actively treated 64% of patients on POD 0-1 and 100% of patients were treated by POD 2. Minimal patchy graft loss (median 1.5%) was noted in 6 grafted areas including 1 area which crossed a knee despite immobilization. No graft loss was related to POM and was attributed to factors including infection or wound conversion and, by definition, no significant graft loss was found.ConclusionsWhile the sample size is limited, this study suggests early POM of ASCS is safe and does not lead to graft loss. Considerations for mobilization techniques, such as ROM and functional mobility, should include joint involvement, presence of STSG with ASCS overspray, and other patient factors such as health literacy and compliance. Additional prospective studies should be dedicated to the examination of POM to develop clinical practice guidelines which can be widely utilized across burn therapy.

Double-Row Suture Anchor Fixation and Achilles Allograft Augmentation for Chronic Patellar Tendon Rupture Repair

Patellar tendon ruptures are functionally devastating injuries that result in failure of the knee extensor mechanism and can lead to a loss of ambulation. Chronic patellar tendon injuries are defined as tears greater than 2 weeks old and are typically more complex to manage than acute tears. Recently, the use of double-row suture anchor configurations has been explored as a technique to provide improved strength in addition to tendon-to-bone compression at the anatomic footprint. The purpose of this article is to describe a surgical technique involving chronic patellar tendon rupture repair using a double-row suture construct augmented with Achilles allograft. Our technique offers a variety of benefits and permits early postoperative mobilization.

Treatment of comminuted fractures of the bones of the lower leg with rod and pincer apparatus

From 1997 to 1999 thirty eight patients with splintered and polyfocal crus fractures (9 patients had open fractures) were treated by transosseous osteosynthesis using rod or pin-rod devices. Splintered diaphyseal fractures were of В and C groups according to AO/ASIF classification but peri- and intraarticular fractures were of A2,3 and C groups. In fractures with large intermediate fragments an universal reposition device with floating fixators of rods was applied. In cases of peri- and intraarticular fractures as well as in fractures with small intermediate fragments Gorodnichenkos pin-rod device was used. The device provided stable fixation and patients with diaphyseal crus fractures were allowed full weight bearing from 3-5 postoperative day. The operative intervention is a low traumatic one that promotes early postoperative mobilization of patients, decreases the term of hospital treatment (mean 8.9 days). Fracture healing was achieved in all patients, no complications such as the imfiammation of soft tissues surrounding pins or rods were observed. The fixation was 12-18 weeks.

The influence of weight-bearing status on post-operative mobility and outcomes in geriatric hip fracture

PurposeWe hypothesized that unrestricted or full weight-bearing (FWB) in hip fracture would increase the opportunity to mobilize on post-operative day 1 (POD1mob) and be associated with better outcomes compared with restricted weight-bearing (RWB).MethodsOver 4 years, 1514 geriatric hip fracture patients aged 65 and above were prospectively recruited. Outcomes were compared between FWB and RWB patients. The primary outcome was 30-day mortality. Secondary outcomes were immobility-related adverse events, length of stay (LOS), and reoperation for failure. Causal effect modelling and multivariate regression with mediation analyses were performed to examine the relation between weight-bearing status (WBS), POD1mob, and known mortality predictors.ResultsFWB was allowed in 1421 (96%) of 1479 surgically treated patients and RWB enforced in 58 (4%) patients. Mortality within 30 days occurred in 141 (9.9%) of FWB and 3 (5.2%) of RWB patients. In adjusted analysis, RWB did not influence 30-day mortality (OR 0.42, 95% CI 0.15–01.13, p = 0.293), with the WBS accounting for 91% of the total effect on mortality and 9% contributed from how WBS influenced the POD1mob. RWB was significantly related to increased DVT (OR 7.81, 95% CI: 1.81–33.71 p = 0.002) but no other secondary outcomes. Patients that did not have the opportunity to mobilize had increased 30-day mortality (OR 2.31, 95% CI 1.53–3.48 p < 0.001).ConclusionRestricted weight-bearing was not associated with increased 30-day mortality. Only a small proportion of this effect was mediated by POD1mob. Whilst post-surgical WBS may be difficult to influence for cultural reasons, POD1mob is an easily modifiable target that is likely to have a greater effect on 30-day mortality.Level of evidenceLevel III, observational study.

Cumulated ambulation score as predictor of postoperative mobility in patients with proximal femur fractures.

The cumulated ambulation score (CAS) has been developed as an index for evaluating mobility in the early postoperative period. This study aimed to estimate the association between CAS and independent ambulation after surgery for proximal femur fractures. This retrospective cohort study included 223 elderly patients who underwent surgery for proximal femur fractures and had independent ambulation before the injury. Multivariable logistic regression analyses with cognitive impairment, pre-injury Barthel index, and CAS as the test variables were used to predict independent ambulation at 2weeks (model 1) and 3months (model 2) postoperatively. We established scoring systems based on the modeling results. The number of patients with independent ambulation at 2weeks and 3months postoperatively was 115 and 169, respectively. Univariate analysis showed that the CAS was significantly associated with independent ambulation at 2weeks and 3months postoperatively. Multivariable analysis showed that models 1 and 2 had good predictive accuracies, with areas under the receiver-operating characteristic curve of 0.855 and 0.868, respectively. Among the explanatory variables, only the CAS in model 2 was not significantly associated with the postoperative ambulatory ability. Scoring systems for both models 1 and 2 also had good predictive accuracies, with cut-off scores of 3.5 for model 1 and 9.5 for model 2. The CAS predicted independent ambulation at 2weeks postoperatively; however, this relationship was limited at 3months postoperatively. Therefore, the CAS may help estimate independent ambulation at discharge from an acute-care hospital.

A Retrospective Study on the Effects of Kinesiology Taping on Edema of the Lower Limb in 14 Patients Following Intramedullary Nailing for Femoral Shaft Fracture.

BackgroundKinesiology tape indications of use include pain mitigation, neurosensory input, and promotion of circulation. Current evidence suggests that residual functional limitations following intramedullary nailing of the femoral shaft may be due to soft tissue injury and compromise. This retrospective study from a single center aimed to compare the effects of kinesiology taping on edema of the lower limb in 14 patients following intramedullary nailing for femoral shaft fracture.Material/MethodsThe randomized control trial design consisting of 2 groups totaling 14 patients. The intervention group (n=7) received standard therapy and kinesiology tape decompression/fan application. The control group (n=7) received standard therapy with no kinesiology tape. Outcome measures included limb girth tape measurements, Visual Analog Scale (VAS) for pain, involved knee ROM goniometry, and Timed Up and Go (TUG).ResultsResults of this study showed there was a decrease in limb volume in the control group and an increase in limb volume in the intervention group. Both groups had improvements in TUG scores. The only statistically significant finding was among the control group, which had a decrease of 1.6 in mean VAS score before and after IM nailing (P=0.010).ConclusionsIn this study from a single center, kinesiology tape in patients with intramedullary nailing for femoral shaft fracture did not significantly reduce the volume of the lower limb, reduce pain, or improve postoperative mobility. The only significant improvement from the use of kinesiology tape was improved active knee extension due to improvement in quadriceps force.

Peroperative Intra-Articular Infiltration of Tranexamic Acid and Ropivacaine Cocktail in Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Trial.

BackgroundTotal knee arthroplasty (TKA) is a procedure that has improved the quality of life of patients with knee arthritis. Postoperative pain and blood loss are the two major drawbacks of TKA which affect patient satisfaction and delay recovery and rehabilitation. Local infiltration analgesia has shown better results in controlling immediate postoperative pain, thus enabling early rehabilitation and mobilization, while local infiltration of antifibrinolytic agents has shown impressive results in controlling blood loss. In this study, we evaluate the effect of a combination of intra-articular infiltration of ropivacaine cocktail along with intra-articular instillation of tranexamic acid in reducing patient-reported postoperative pain and the level of blood loss control after TKA.MethodologyPatients presenting with high-grade osteoarthritis and undergoing TKA were included and randomly allocated to two groups: one receiving the intra-articular infiltration (group A), and the other not receiving any infiltration (group B). Postoperative pain was measured through the Visual Analog Scale (VAS) every three hours for the first 24 hours, and then at 48 hours and 72 hours postoperatively. The need for additional analgesia, in the form of a slow epidural infusion, in patients experiencing severe postoperative pain was evaluated in both groups. Postoperative blood loss was assessed by measuring total drain output (in mL) and by comparing preoperative and postoperative (at 24 hours) hemoglobin, hematocrit drift, and blood transfusion rates. The duration of the postoperative hospital stay and the time taken to start postoperative knee mobilization exercises and weight-bearing were noted to assess the recovery and rehabilitation of the patients in the two groups.ResultsThe study included 42 patients (group A, 22 patients; group B, 20 patients) with 28 knees in each group. Patients with intra-articular infiltration using ropivacaine cocktail with tranexamic acid showed excellent pain control compared to the non-infiltrated patients in the early 48 hours postoperatively. There was a significant drop in postoperative hemoglobin and hematocrit values in the non-infiltrated patients compared to the other group. Further, the intra-articular infiltration-instillation significantly reduced blood loss through the drain, the requirement of postoperative blood transfusions, and the duration of hospital stay.ConclusionsIt can be safely concluded that ropivacaine cocktail and tranexamic acid instillation postoperatively in knee arthroplasty patients is a very useful and effective technique to reduce postoperative pain and blood loss.

Rehabilitation to improve outcomes of lumbar fusion surgery: a systematic review with meta-analysis.

To evaluate the effectiveness of rehabilitation strategies on disability, pain, pain-related fear, and return-to-work in patients undergoing lumbar fusion surgery for degenerative conditions or adult isthmic spondylolisthesis. Six electronic databases were systematically searched for randomized controlled trials (RCTs) evaluating the effect of rehabilitation (unimodal or multimodal). The estimated effect size was calculated for interventions with homogeneous content using a random-effects model. Certainty of evidence was assessed by GRADE. In total, 18 RCTs, including 1402 unique patients, compared specific rehabilitation to other rehabilitation strategies or usual care. Most described indications were degenerative disc disease and spondylolisthesis. All rehabilitation interventions were delivered in the postoperative period, and six of them also included a preoperative component. Intervention dose and intensity varied between studies (ranging from one session to daily sessions for one month). Usual care consisted mostly of information and postoperative mobilization. At short term, low quality of evidence shows that exercise therapy was more effective for reducing disability and pain than usual care (standardized mean difference [95% CI]: -0.41 [-0.71; -0.10] and -0.36 [-0.65; -0.08], four and five studies, respectively). Multimodal rehabilitation consisted mostly of exercise therapy combined with cognitive behavioral training, and was more effective in reducing disability and pain-related fear than exercise therapy alone (-0.31 [-0.49; -0.13] and -0.64 [-1.11; -0.17], six and four studies, respectively). Effects disappeared beyond one year. Rehabilitation showed a positive tendency towards a higher return-to-work rate (pooled relative risk [95% CI]: 1.30 [0.99; 1.69], four studies). There is low-quality evidence showing that both exercise therapy and multimodal rehabilitation are effective for improving outcomes up to six months after lumbar fusion, with multimodal rehabilitation providing additional benefits over exercise alone in reducing disability and pain-related fear. Additional high-quality studies are needed to demonstrate the effectiveness of rehabilitation strategies in the long term and for work-related outcomes.

BONE DEFECT MANAGEMENT AND AUGMENTATION OF DISTAL FEMORAL FRACTURES WITH POLYMETHYLMETHACRYLATE BONE CEMENT

Fragility distal femoral fractures are often associated to deficient bone stock and bone defect. Frail patients, who are characterized by their coexisting comorbidities, low functional status and frequent cognitive impairment, benefit from early intervention and mobilization. The use of polymethylmethacrylate bone cement in the case of distal femoral fractures with decreased screw purchase and bone defect is a valid option in frail non-ambulatory patients. Given an accurate patient selection, the immediate postoperative mobilization provided by the one-shot surgery presented in this paper procures substantial advantages.

Current State of ERAS Implementation in Thoracic Surgery in Germany

In recent years, ERAS treatment pathways have found their way into many surgical fields, as they reduce complications and accelerate postoperative recovery. For thoracic surgery, the first ERAS guidelines were published by the ERAS Society and the European Society of Thoracic Surgeons (ESTS) in 2019. We have now evaluated how ERAS-items are implemented in clinical practice by using an online survey. An online survey was conducted from 12/5/2021 until 1/6/2021. The survey consisted of 22 questions focusing on the key elements of an ERAS program according to the published ERAS guidelines. Results were summarised, descriptively analysed and put into context with the current literature. Of 155 thoracic surgeons, 32 responded to the survey. In 28.1% (n=9) of the hospitals, an ERAS core unit was established, and a database to record the ERAS items existed in 15.6% (n=5). Only 3.1% (n=1) kept an ERAS-diary preoperatively. A so-called Carboloading was conducted at 15.6% (n=5) of surgeons. Standard PONV prophylaxis was administered to 59.4% (n=19) of the patients. In most cases (84.4%, n=29), a single drain was inserted into the pleural cavity during anatomic resections. In 3% (n=1) of the centres two drains, in 12.5% (n=4) no drainage was placed. The most commonly applied initial suction was -10 cmH2O (75%, n=24). Suction ≤2cmH2O was used by only two of those interviewed. Drainage removal took place in 50% (n=16) of cases between the 1st or 2nd POD, in 34.4% of cases (n=11) between the 3rd and 4th POD and in 9.4% (n=3) the drain remained longer than the 4th POD. The first postoperative mobilisation took place in 71.9% (n=23) of the centres on the day of the operation. The implementation of ERAS guidelines varies in Germany between centres. Certain perioperative processes are covered sufficiently, but the implementation of key features of ERAS is yet to be fully established in clinical practice. The first steps in this direction have already been taken and lay the foundation for cooperation across centres.

The Effect of Postoperative Early Mobilization on the Healing Process and Quality of Life Following Radical Cystectomy and Ileal Conduit: A Randomized Prospective Controlled Trial

The Effect of Postoperative Early Mobilization on the Healing Process and Quality of Life Following Radical Cystectomy and Ileal Conduit: A Randomized Prospective Controlled Trial