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Background/Aim. Peripheral nervous system affection in people with lung cancer is commonly associated with paraneoplastic neuropathy. However, clinical studies evaluating the frequency, clinical, and electrophysiological characteristics of peripheral neuropathies which are not related to onconeuronal antibodies, in this, on average, older population of patients, are very rare. The aim of this study was to define the frequency, as well as clinical and electrophysiological characteristics of idiopathic neuropathies in patients suffering from lung cancer in early stages of the diseases. Methods. Clinical and electrophysiological data of 105 elderly subjects (age 63.4 ± 7.8 years) suffering from lung carcinoma who underwent extensive neurological and electrophysiological evaluation (nerve conduction studies) between 2013–2018 were estimated. Exclusion criteria were “classical” paraneoplastic neurological syndromes with onconeuronal antibodies present, as well as patients with typical known causes of peripheral neuropathy (e.g. diabetes, alcoholism, chronic renal insufficiency, vitamin deficiencies, etc.). Results. There were 19.1% patients with clinically manifest neuropathies, with additional 37.1% patients with only electrophysiological abnormalities. The most frequent pathophysiological pattern was axonal pathology (71.2%) with predominantly distal and symmetrical distribution (86.4%). Conclusion. Patients with lung cancer in the early stages of the disease show a high incidence of clinically minor damage of the nerves, according to the pattern of chronic sensomotor distal neuropathy, with predominance of axonal damage. These findings underline the importance of a detailed clinical and electrophysiological evaluation in this category of patients who are without the typical etiological factors for peripheral neuropathies since, during cancer therapy, patients undergo a series of treatments with additional risk for the development/aggravation of neuropathy. [Project of the Serbian Ministry of Education, Science and Technological Development, Grant no. 175046]

The data about the incidence and risk factors for surgical site infections (SSIs) following total joint arthroplasty (TJA) in middle-income countries are still scant. The aim of this study was to assess the incidence and risk factors associated with 30-day SSIs following total hip arthroplasty (THA) and total knee arthroplasty (TKA). The study was conducted at the Clinic for Orthopedic Surgery and Traumatology, Clinical Center of Serbia (CCS) in Belgrade, from May 2016 to April 2018. All patients undergoing THA or TKA were followed throughout hospitalization until day 30 after discharge. Of the 1073 admitted patients, 459 had THA and 230 had TKA. The incidence rate of surgical site infections (SSIs) among the patients who underwent THA was 5.4%, which is 3.8 per 1000 postoperative patient-days, while the rate among those who had TKA was 4.8%, i.e., 3.4 per 1000 postoperative patient-days. Out of the 36 SSIs, 15 were deep and 21 were superficial incisional ones. Among the variables examined, the independent risk factors for SSIs after THA were the American Society of Anesthesiologists (ASA) score &gt, 2 (RR = 3.17, 95% CI&mdash, 1.26&ndash, 8.02), smoking (RR = 3.14, 7.82) and peripheral vascular disease (PVD) (RR = 6.09, 2.35&ndash, 15.77), and after TKA, only PVD (RR = 3.87, 1.09&ndash, 13.76) was the risk factor. Incidence rates of SSIs after arthroplasty are higher compared to reports from developed countries. Therefore, it is necessary to enhance infection prevention and control measures with strict control of modifiable risk factors.

The aim of this open prospective cohort study was to determine if a prolonged pre-operative hospital stay is a true predictor of higher morbidity or mortality in geriatric patients with hip fractures. We analysed early outcome parameters, such as functional independence measure (FIM), at discharge and four months post-operatively, peri-operative nonsurgical complications, intra-hospital and one year mortality compared with prolonged pre-operative hospital stay in 308 patients from a continuous cohort of 344. Average pre-operative stay was 8.39 ± 5.80 days. Delaying surgery for > 72 hours was independently predictive for general complications and lower motor FIM gain at four months. All findings worsen progressively after the fifth day of delay. Pre-operative period was not found to be an independent predictor of mortality. In all observed outcome parameters except mortality, pre-operative delay > 72 hours was shown to be a true predictive factor.

Medical students are mainly exposed to needle stick and sharp object injuries in the course of their clinical activities during studying. They are at high risk due to their undeveloped skills, restricted clinical experience, lack of knowledge and risk perception. The objectives of this study were to determine the prevalence of needle stick injuries of the fourth and final year medical students, and to estimate their knowledge about blood-borne pathogens disease transmission and standard precautions.This cross-sectional study was conducted at the Faculty of Medicine, in February 2014. The students were invited to self-administer a questionnaire of 26 closed questions prepared for this study.The questionnaire was filled in and returned by 637 students. The prevalence of needle sticks and sharp object injuries was 29.5%. Needle stick injuries were the most common type of accidents, more frequent among the fourth compared to the sixth year students (p=0.002). The majority of accidents occurred in patient rooms (53%) and the emergency department (15%). 54% of participants reported an accident to the responsible person. Students without accidents had a significantly better perception of risk (3.79 vs. 3.35; p0.05). Out of the total participating students, only 16.6% (106/637) received all three doses of Hepatitis B vaccination, while 16.2% were partially vaccinated.There is a need for additional theoretical and practical education of our students on blood exposure via accidents, raising the awareness of the necessity of hepatitis B vaccination, and introducing the unique/comprehensive procedure for accident reporting for students and healthcare workers in the entire country.Študentje medicine so v okviru kliničnih dejavnosti med študijem izpostavljeni predvsem vbodnim poškodbam z iglami ter urezninam z ostrimi predmeti. Zaradi še nerazvitih kliničnih veščin, skromnih kliničnih izkušenj in omejenega znanja je tveganje za poškodbo pri njih višje. Cilj te raziskave je bil zato ugotoviti razširjenost poškodb z iglami in ostrimi predmeti v medicini med študenti četrtega in zadnjega letnika medicine ter oceniti njihovo znanje o boleznih, ki se prenašajo s krvjo, in poznavanje standardnih varnostnih ukrepov.Februarja 2014 smo izpeljali presečno raziskavo na Medicinski fakulteti Univerze v Beogradu. Študentje so bili povabljeni, naj izpolnijo vprašalnik, sestavljen iz 26 vprašanj zaprtega tipa, pripravljenih za to študijo.Vprašalnik je izpolnilo 637 študentov. Razširjenost poškodb z iglami in ostrimi predmeti je bila 29,5-odstotna. Poškodbe z iglami so bile najpogostejša vrsta poškodb nasploh in pogostejša med študenti četrtega letnika v primerjavi s študenti šestega letnika (p=0,002). Večina poškodb se je pojavila v bolniških sobah (53%) in na urgentnih oddelkih (15%). Odgovorni osebi je nezgodo sporočilo 54% udeležencev. Študenti brez poškodb so bistveno bolje zaznavali tveganje (3,79 vs. 3,35; p0,05). Le 51% sodelujočih študentov je bilo v celoti cepljenih proti hepatitisu B.Obstaja potreba po dodatnem teoretičnem in praktičnem izobraževanju naših študentov o izpostavljenosti krvi zaradi poškodb z iglami in ostrimi predmeti, po dvigu zavesti o nujnosti cepljenja proti hepatitisu B in uvajanju celovitega postopka za poročanje o poškodbah z iglami in ostrimi predmeti za študente in zdravstvene delavce v celotni državi.

Introduction: Hip fractures represent an important medical, social, and economical problem of modern age. Between 14% and 36% of people with hip fracture die in the first year after the fracture. The largest number of survivors fail to regain the pre-injury walking ability and level of activity. High rates of mortality and morbidity point out the necessity of identifying and defining the determinants of outcome, which could potentially be influenced on with the aim to reduce mortality, and disability, as are result of this event. The aim: To determine whether two different scales to measure functional disability are equally sensitive predictors of mortality in elderly patients with hip fracture. Materials and Methods: The study included 299 patients older than 65 years that were operatively treated at the Institute for Orthopaedic Surgery and Traumatology for a period of one year, due to acute hip fracture. Preoperatively, patients were questioned regarding socio-demographic variables, cognitive status, functional disability before the accident, type of hip fracture and operational risk. Functional disability before the accident was measured using the motor subscale of the functional test of independence (motor FIM) and Barthel index. In order to examine the association between different preoperative variables and intrahospital/one-year mortality as starting variables, multivariate logistic regression analysis were performed, in which the influence of motor FIM and the Barthel index were examined separately. Results: The study confirmed that patients who had a higher level of functional disability before fracture, have a higher risk of short-term and long-term mortality after hip fracture. The most important result of this work is that Barthel's index and motor FIM test are equally effective predictors of short-term and long-term mortality. Conclusion: Our study revealed the importance of functional impairment prior to injury, for the prediction of mortality after hip fracture. Because of its simplicity the Barthel index should be the test of choice for the evaluation of pre-injury functional disability in patients with hip fractures.

Evolution of intensive care medicine in the last few decades and integrating teamwork has a major impact on increasing the rate of survival of patients. All the attention of the responsible team is not only aimed at treating the underlying disease, but also to decrease complications associated with prolonged stay in the ICU. The most common complications are: deconditioning, muscle weakness, polyneuropathy, myopathy, thromboembolic complications, decubital wound, artculation stiffness, cognitive disorders, depression, anxiety and a global reduction in quality of life. Physical therapy has its place in the earliest stages of treatment of mechanically ventilated patients. The aim of this article is to review the evidence for the use of rehabilitation in ICU in the adult mechanically ventilated patients. Early and systematically structured rehabilitation programs have been shown to be both safe and feasible for critical care populations.

Decreased muscle strength is not only a risk factor for hip fracture in elderly patients, but plays a role in recovery of physical function. Our aim was to assess the role of grip strength measured early after hip fracture, and classified according to the EWGSOP2 criteria in predicting short- and long-term functional recovery. One hundred ninety-one patients with acute hip fracture consecutively admitted to an orthopaedic hospital have been selected. A multidimensional geriatric assessment evaluating sociodemographic variables, cognitive status, functional status and quality of life prior to fracture, as well as perioperative variables were performed. Follow-ups at 3 and 6 months after surgery were carried out to evaluate functional recovery. Multivariate regression models were used to assess the predictive role of handgrip strength. The mean age of the participants was 80.3 ±6.8 years. Thirty-five percent of our patients with clinically relevant hand grip strength weakness were significantly older, more often female, had a lower BMI, and were of worse physical health. They also had a lower cognitive level, lower Barthel index, and lower EQ5D scores before fracture. Multivariate regression analysis adjusted for age and gender revealed that hand grip weakness was an independent predictor of worse functional outcome at 3 and 6 months after hip fracture for both genders and in all age populations. Our study supports the prognostic role of hand grip strength assessed at hospital admission in patients with hip fracture. Thus, clinicians should be encouraged to include hand grip assessment in their evaluation of hip fracture patients in the acute setting in order to optimize treatment of high-risk individuals.

Aim We aimed to evaluate the factors contributing to delirium after hip fracture and assess the effect of incident delirium on short-term clinical outcomes. Methods A total of 270 non-delirious, consecutive hip fracture patients 60 years and older were included in a prospective cohort study. The patients were assessed with respect to physical status according to the American Society of Anesthesiologists classification, medical comorbidities with the Charlson Comorbidity Index, cognitive function with the Portable Mental Status Questionnaire and depression with the Geriatric Depressive Scale. Incident delirium was evaluated daily. Clinical outcomes and 1-month mortality were recorded. Results Incident delirium was present in 53.0% of patients. Patients with delirium were older (P = 0.046), had higher American Society of Anesthesiologists and Charlson Comorbidity Index scores (P

Objectives: To analyze the incidence of the overlap syndrome of depressive symptoms and delirium, risk factors, and independent and dose-response effect of the overlap syndrome on outcomes in elderly adults with hip fracture. Design: Prospective cohort study. Setting: University hospital. Participants: Individuals with hip fracture without delirium (N = 277; aged 78.0 ± 8.2) consequently enrolled in a prospective cohort study. Measurements: Depressive symptoms were assessed using the Geriatric Depression Scale and cognitive status using the Short Portable Mental Status Questionnaire upon hospital admission. Incident delirium was assessed daily during the hospital stay using the Confusion Assessment Method. Information on complications acquired in the hospital, severity of complications, re-interventions, length of hospital stay, and 1-month mortality was recorded. Results: Thirty (10.8%) participants had depressive symptoms alone, 88 (31.8%) delirium alone, 60 (21.7%) overlap syndrome, and 99 (35.7%) neither condition. According to multivariate regression analysis, participants with the overlap syndrome had significantly higher incidence of vision impairment (P = .02), longer time-to-surgery (P = .03), and lower cognitive function (P < .001) than participants with no depressive symptoms and no delirium. In the adjusted regression analysis, participants with neither condition were at lower risk of complications than those with the overlap syndrome (P = .03). After adjustment, participants with the overlap syndrome were at higher risk of longer hospital stay independently (P = .003) and in a dose-response manner in the following order: no depression and no delirium, depressive symptoms alone, delirium alone, and the overlap syndrome (P = .002). Conclusion: Depressive symptoms and delirium increase the likelihood of adverse outcomes after hip fracture in a step-wise manner when they coexist. To reduce the risk of adverse outcome in individuals with hip fracture, efforts to identify, prevent, and treat this condition need to be increased.

Introduction: A minority of patients with hip fractures sustain concomitant wrist fractures. Little is known about the rehabilitation outcome in this group of patients. Aim of study: Prospective investigation of functional outcome and survival in patients with combined hip and wrist fractures compared with patients who sustain an isolated hip fracture. Methods: 341 patients who presented with an acute hip fracture during a 12 month period were included in the study. Outcome at discharge and 4 months follow-up was compared between patients with isolated hip fractures and those patients who sustained simultaneous distal wrist fractures. Results: The actual incidence of concurrent hip and wrist fractures in our cohort was 4.7%. Patients who sustained a concurrent hip and wrist fracture showed no differences regarding short- and long-term functional outcome and survival. Conclusion: Our results imply that patients with simultaneous hip and wrist fractures have no difference in rehabilitative outcome. Future studies should further investigate the distinctive characteristics of this patient subgroup.

Decreased muscle strength is not only a risk factor for hip fracture in older patients, but plays a role in recovery of physical function. Our aim was to assess the role of grip strength measured early after hip fracture, and classified according to the EWGSOP2 criteria in predicting short- and long-term functional recovery. One hundred ninety-one patients with acute hip fracture consecutively admitted to an orthopaedic hospital have been selected. A multidimensional geriatric assessment evaluating sociodemographic variables, cognitive status, functional status and quality of life prior to fracture, as well as perioperative variables were performed. Follow-ups at 3 and 6 months after surgery were carried out to evaluate functional recovery. Multivariate regression models were used to assess the predictive role of handgrip strength. The mean age of the participants was 80.3 ±6.8 years. Thirty-five percent of our patients with clinically relevant hand grip strength weakness were significantly older, more often female, had a lower BMI, and were of worse physical health. They also had a lower cognitive level, lower Barthel index, and lower EQ5D scores before fracture. Multivariate regression analysis adjusted for age and gender revealed that hand grip weakness was an independent predictor of worse functional outcome at 3 and 6 months after hip fracture for both genders and in all age populations. Our study supports the prognostic role of hand grip strength assessed at hospital admission in patients with hip fracture. Thus, clinicians should be encouraged to include hand grip assessment in their evaluation of hip fracture patients in the acute setting in order to optimize treatment of high-risk individuals.

Hip fractures are the most serious consequence of falling in older people with osteoporosis. Early ambulation is one of the main goals of inpatient rehabilitation aimed at reducing negative effects of immobilization, and promoting functional recovery. Recognizing the role of different factors that are associated with time to ambulation time after hip fracture surgery may help decrease morbidity and mortality rates. The aim of this study was to examine the impact of postoperative pain time to ambulation following hip fracture surgery. A total of 96 patients who consecutively presented at the Clinic for Orthopaedic Surgery and Traumatology, Clinical Center Serbia during a 6 month period were included in the study. Subjects were assessed regarding socioedemographic characteristics, prefracture functional status, cognitive status, general health status, fracture type, type of anaesthesia, and waiting time for surgery. The VAS scale (0-100) was used to measure pain intensity on the first postoperative day. Our results revealed that patients, whose time to ambulation was =48h postoperatively were of worse physical health, and had significantly higher VAS score on the first postoperative day. Unrelieved pain in geriatric hip fracture patients is associated with delayed ambulation. Future research should confirm the positive effects of aggressive pain management programs on early functional outcome in elderly patients who sustain hip fractures.

Background A growing body of evidence supports the effectiveness of using transcranial direct current stimulation (tDCS) in patients with chronic hand motor impairment resulting from stroke. Objective In this study, we investigate and compare the combined effects of anodal tDCS and occupational therapy (OT) to sham stimulation with OT (control) on fine motor skill deficits of chronic stroke patients. Methods A total of 26 stroke patients (at ≥ 9 months) were randomly assigned to an active treatment or a control group in a double-blinded, sham-controlled, parallel design study. Each group received OT for 45 min/day (10 sessions for 2 weeks). Treatment was preceded by either 20 minutes of 2 mA anodal tDCS over ipsilesional M1 or sham tDCS. A modified Jebsen-Taylor Hand Function Test (mJTHFT) was administered as primary outcome measure, and handgrip dynamometer and upper limb Fugl-Meyer (ULFM) assessments were performed as secondary outcomes. The assessment was done at baseline (T0), after the interventions on day 1(T1), day 10 (T2) and day 40 (T3). Results We observed a statistically significant effect in the tDCS group when the results were compared to the sham group. The mJTHFT times were significantly shorter immediately after treatment and at day 40. The intervention had no effect on handgrip strength or ULFM score. Conclusion Fine motor skill deficits in chronic stroke survivors can be improved when intensive OT is primed with anodal tDCS over the ipsilesional hemisphere.

Hip fractures remain one of the most devastating injuries in the elderly. Early prediction of outcome following hip fracture potentially results in more efficient health care. The aims of this study were to explore predictors of ambulation status at hospital discharge in patients ≥65 years of age operated on for fracture of the hip, and to investigate the impact of ambulation status at hospital discharge on 1-year mortality after hip fracture. We studied 344 patients who underwent surgery for hip fracture during a 12 month period. Multivariate regression analysis was used to explore predictive factors for ambulatory status at discharge, and 1-year mortality adjusted on important baseline variables. Cumulative 1-year mortality was significantly lower for patients in the ambulatory group when compared to patients in the non-ambulatory group. Patients who were older, had severe cognitive impairment, lower functional level before injury, and in whom postoperative delirium and pressure ulcers occurred had a higher chance of not recovering their gait ability at hospital discharge, and being dead 1 year after hip fracture.Inability to walk at hospital discharge and presence of delirium are independent predictors of 1-year mortality. Every effort should be made to assure early mobilisation after hip fracture surgery, and prevention, prompt recognition and treatment of postoperative complications is important in order to facilitate better short-and long-term outcome.

Introduction The aim of the study was to determine to what extent severe cognitive impairment impacts short-term rehabilitation outcomes of elderly patients with proximal hip fracture. Material and methods A total of 337 community-dwelling elderly patients with acute hip fracture were observed during a 12-month period at a major teaching hospital in Serbia. Cognitive status was assessed at admission with the Short Portable Mental Status Questionnaire (SPMSQ). Outcome after 4 months was analysed with respect to presence of severe cognitive impairment, defined as an SPMSQ score of < 3. Outcome assessment included presence of postoperative complications, absolute motor Functional Independence Measure (FIM) gain, Activities of Daily Living index (ADL), Instrumental Activities of Daily Living score (IADL), and walking ability. Results An SPMSQ score of < 3 was observed in 36 patients (10.7%) with acute hip fracture. Patients with an SPMSQ score of < 3 achieved worse short-term outcomes regarding all observed variables. However, cognitive status was found to be an independent predictor only with respect to mortality at 4 months (odds ratio (OR) = 0.969, 95% confidence interval (CI) = 0.947-0.992, p = 0.009). In contrast, pre-fracture motor FIM independently predicted mortality (OR = 2.982, 95% CI = 1.271-7.000, p = 0.012), and preserved walking ability at 4 months follow-up (OR = 0.945, 95% CI = 0.912-0.980, p = 0.002). Correspondingly, pre-fracture ADL was an independent predictor of absolute motor FIM gain at 4 months follow-up (OR = 0.175, 95% CI = 0.405-11.426, p = 0.035). Conclusions Failure to consider functional status prior to fracture might overestimate the impact of cognitive status on functional outcome of hip fracture patients.

Hip fracture in elderly people is associated with high morbidity and mortality. Therefore, it is important to identify risk factors that potentially influence outcomes after hip surgery. The main purpose of this study was to evaluate the relationship of anemia at admission and short-term outcomes after hip fracture. We studied 343 community-dwelling patients who underwent surgery for hip fracture from March 2009 to March 2010. Functional mobility at discharge, postoperative complications, hospital length of stay and in-hospital mortality were analyzed in respect to presence and severity of anemia at admission. Anemia (defined as hemoglobin levels < 13.0 g/dl for men and < 12.0g/dl for women) was present in 185 (53.9%) patients, of whom 54 (29.2%) were severely anemic (defined as hemoglobin level 10.0g/dl or below). In multivariate analysis anemia was associated with age, gender (female), type of fracture (intertrochanteric) and American Society of Anesthesiologists (ASA) classification (3 or 4), while severity of anemia was associated with recovery of ambulatory ability at discharge. There was no difference in the incidence of postoperative complication, in-hospital mortality and length of hospital stay between the groups at discharge. Overall anemia at admission is an indicator of poor general health status. Ambulatory recovery in hip fracture patients is independently related to severity of anemia at admission.

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One of the most important technical demands in ACL surgery is good fixation of the graft. Integrity of the posterior femoral cortex is necessary for Interference screws fixation. The femoral tunnel, placed as posterior as possible, is also mandatory for good graft position and potentially leads to violation of the cortex. The divergence between screw and tunnel could result in perforation of the posterior wall. Without intraoperative x-ray it is difficult to be sure that position of the screw is correct, even with good graft tension. Still, the problem exists with absorbable screws. The aim of the study is to show results of 6 patients with this complication treated without revision of the femoral fixation with mean follow up of 1,5 year. Potential pitfall in ACL reconstruction is posterior cortex breakout and loss of fixation. If it is recognized during surgery changing the type of fixation can solve the problem, but if not, in the early phase of rehabilitation and weight bear, graft failure is feasible. The tibia tunnel angle and length, the footprint of femoral tunnel reamer and hyper flexion of the knee during screw insertion are methods for preventing the breakout of the posterior wall and screw-tunnel divergence. Modification of the early postoperative treatment and less aggressive rehabilitation protocol reduced the need for revision surgery. Even with best surgical technique, skill and experience this complication is possible to occur.

The aim of this paper was to determine whether the change in the position of the patient’s leg as well as the use of flexible reamers may help in obtaining a longer femoral tunnel with minimal risk of perforating the posterior cortex. One hundred and twenty-five patients who had undergone anatomic ACL reconstruction between 2010 and 2013 were included in this prospective cohort study. The first group was composed of patients whose femoral tunnel had been drilled with rigid reamers, while the leg being operated on was positioned on an arthroscopic leg holder (82 patients). In the second group of patients, the femoral tunnel was also drilled with rigid reamers, but the leg was positioned on the table (25 patients), while the third group was composed of patients whose femoral tunnel was drilled with flexible reamers, and the leg was positioned on a leg holder (18 patients). The length of the femoral tunnel was measured intraoperationally, while the site of femoral insertion and the position of the tunnel were read from native radiographic images. When the femoral tunnel was drilled on the medial aspect of the lateral condyle, the centre of the tunnel was located at 31.4 % from the most proximal point of the femoral condyle and 34.7 % from the Blumensaat line. The length of the tunnel drilled with rigid reamers on the operating table (36.1 mm) was statistically significantly greater (p

Rehabilitation after ACL (anterior cruciate ligament) reconstruction has drastically changed over the last decade, with the adoption of a more aggressive approach, right from the first day after surgery. Progress in the effectiveness of rehabilitation is based on improvements in operative techniques, as well as on the encouraging results of histological studies regarding graft healing. Despite a huge amount of research papers on this topic, a rehabilitation golden standard still has not been established, due to the complexity of this problem. In this review, we point out the basic principles of rehabilitation after arthroscopically assisted ACL reconstruction based on actual practices, as well as the importance of specific procedures for the prevention of complications during the postoperative period. The importance of range-of-motion exercises, early weight bearing, an appropriate gait scheme, patella mobilisation, pain and oedema control, as well as stretching and balance exercises is explained. The functional advantages of closed kinetic chain exercises, as well as their influence on the graft are also described, in comparison to open kinetic chain exercises. The fundamentals of returning to sports are revealed and the specific aspects of rehabilitation regarding graft choice are pointed out. While waiting for new clinical investigations, which are expected to enable the establishment of a rehabilitation golden standard, the outlined principles should be followed. The complexity of this injury requires treatment in highly specialised institutions.

ACL injury leads to a decrease in proprioceptive abilities, which can be improved with ACL surgery and postoperative rehabilitation. The goal of our study was to investigate whether the impact of coordinative training can be differentiated from the influence of surgery on proprioceptive improvement, and whether there is a correlation between improvement in coordinative abilities and other objective parameters of functional recovery. This follow-up study included 45 patients who had undergone ACL reconstruction and who were randomized into a conservative (TH-C) and an intensive (TH-I) rehabilitation group. In the TH-I group, coordinative training began earlier due to unrestricted weight-bearing. The groups were first compared preoperatively, then postoperatively, after 6 weeks, 4,6,9, and 12 months via the single leg stance test, the one leg hop test, the Lysholm knee score, and the Tegner score. A faster recovery of coordinative skills was registered in the TH-I group. Already after 6 weeks, highly statistically significant progress in one leg stance abilities was noticed, while in the TH-C group the same was not noticed until 4 months after surgery (p

We aimed to evaluate the factors contributing to delirium after hip fracture and assess the effect of incident delirium on short-term clinical outcomes.A total of 270 non-delirious, consecutive hip fracture patients 60 years and older were included in a prospective cohort study. The patients were assessed with respect to physical status according to the American Society of Anesthesiologists classification, medical comorbidities with the Charlson Comorbidity Index, cognitive function with the Portable Mental Status Questionnaire and depression with the Geriatric Depressive Scale. Incident delirium was evaluated daily. Clinical outcomes and 1-month mortality were recorded.Incident delirium was present in 53.0% of patients. Patients with delirium were older (P = 0.046), had higher American Society of Anesthesiologists and Charlson Comorbidity Index scores (P 0.001), lower Portable Mental Status Questionnaire scores and higher Geriatric Depressive Scale scores (P 0.001, P = 0.003, respectively). After adjusting for age, multivariate regression analysis in the first model showed that patients with delirium were at higher risk of reintervention plus death (P 0.05), complications P 0.001), a higher severity complication score (P 0.05) and longer length of hospital stay (P 0.001). In the second model, after adjusting for propensity score, patients with delirium were at higher risk of reintervention plus death (P 0.05) and longer length of hospital stay (P 0.01).Patients who are older, with worse physical status, worse cognitive function and depression are more likely to develop delirium after hip fracture. Incident delirium has negative independent effects on short-term outcomes in elderly patients after hip fracture.

Hip fractures in the elderly are followed by increased mortality, which is highest in the period immediately after the fracture. Predictors for early mortality have neither been well identified nor summarized. Identification of early postoperative mortality predictors enables the stratification of high-risk patients and can help in the development of strategies aimed at reducing risk and improving outcome after hip fracture. The primary aim of this study was to investigate the incidence of 30-day mortality. The secondary aim was to investigate factors related to early mortality.We examined 384 elderly patients with hip fracture. Multivariate logistic regression analysis was used to explore independent prognostic factors for 30-day mortality.By the end of the 30-day follow-up period, 22 patients (6.4%) had died. Postoperative delirium was the only variable independently related to 30-day mortality after hip fracture. Older, male patients with a lower cognitive status had a higher chance of developing postoperative delirium.Postoperative delirium is a strong independent marker of high risk for 30-day mortality. Older, male patients with more severe cognitive impairment are at increased risk of developing postoperative delirium. Identifying patients at risk for developing postoperative delirium upon admission and early detection of delirium enable the development of targeted prevention and intervention strategies in older patients with hip fracture.

The aim of this study was to identify risk factors for severe postoperative pain immediately after hip-fracture surgery.Three hundred forty-four elderly patients with an acute hip fracture were admitted to the hospital during a 12-months period. All patients who entered the study answered a structured questionnaire to assess demographic characteristics, previous diseases, drug use, previous surgery, and level of education. Physical status was assessed through the American Society of Anesthesiologists' preoperative risk classification, cognitive status using the Short Portable Mental Status Questionnaire, and depression using the Geriatric Depression Scale. The presence of preoperative delirium using the Confusion Assessment Method was assessed during day and night shifts until surgery. Pain was measured using a numeric rating scale (NRS). An NRS ≥ 7 one hour after surgery indicated severe pain.Patients with elementary-level education (8 yr in school) presented a higher risk for immediate severe postoperative pain than university-educated patients (12 yr in school) (P0.05). Higher cognitive function was associated with higher postoperative pain (P0.01). Patients with symptoms of depression and patients with preoperative delirium presented a higher risk for severe pain (P0.05, P0.01, respectively). Multivariate analysis showed that depression and a low level of education were independent predictors of severe pain immediately after surgery.Depression and lower levels of education were independent predictors of immediate severe pain following hip-fracture surgery. These predictors could be clinically used to stratify analgesic risk in elderly patients for more aggressive pain treatment immediately after surgery.

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This study investigated the combined effects of anodal tDCS and intensive motor training (MT) vs. sham stimulation with MT (control intervention) on grip strength, motor performance and functional use of the affected arm. A total of 14 patients were randomly assigned to active stimulation treatment or a control intervention in a double-blinded, sham-controlled, parallel design. Each group received intensive MT for 45 min/day, 5 days/week, for 2 weeks, preceded by 20 min of 2 mA anodal tDCS over the ipsilesional M1 vs. sham tDCS. The Jebsen Taylor Hand Function Test (JTHFT), hand dynamometer and Fugl-Meyer Assesment (FMA) are tested at baseline, and after each intervention at Day 1, Day 10 and Day 30. The time required to complete the JTHFT between affected and non-affected hand was 81.65 ± 29.61 and 33.00 ± 3.59, respectively. At T 2 significant time shortening for total JTHFT (28.69 ± 18.51) was observed in affected hand. During follow up evaluation at T 3 preiously observed improvements were sustained. Considering grip strength and FMA score, we did not found any relevant changes. Our findings suggest that functional ability consequences of chronic hand motor impairment among stroke survivors, could be improved with anodal tDCS over ipsilesional cortex when coupled with intensive motor training.

Hip fractures in the elderly are followed by considerable risk of functional decline and mortality.The purposes of this study were to (1) explore predictive factors of functional level at discharge, (2) evaluate 1-year mortality after hip fracture compared with that of the general population, and (3) evaluate the affect of early functional outcome on 1-year mortality in patients operated on for hip fractures.A total of 228 consecutive patients (average age, 77.6 ± 7.4 years) with hip fractures who met the inclusion criteria were enrolled in an open, prospective, observational cohort study. Functional level at discharge was measured with the motor Functional Independence Measure (FIM) score, which is the most widely accepted functional assessment measure in use in the rehabilitation community. Mortality rates in the study population were calculated in absolute numbers and as the standardized mortality ratio. Multivariate regression analysis was used to explore predictive factors for motor FIM score at discharge and for 1-year mortality adjusted for important baseline variables.Age, health status, cognitive level, preinjury functional level, and pressure sores after hip fracture surgery were independently related to lower discharge motor FIM scores. At 1-year followup, 57 patients (25%; 43 women and 14 men) had died. The 1-year hip fracture mortality rate compared with that of the general population was 31% in our population versus 7% for men and 23% in our population versus 5% for women 65 years or older. The 1-year standardized mortality rate was 341.3 (95% CI, 162.5-520.1) for men and 301.6 (95% CI, 212.4-391.8) for women, respectively. The all-cause mortality rate observed in this group was higher in all age groups and in both sexes when compared with the all-cause age-adjusted mortality of the general population. Motor FIM score at discharge was the only independent predictor of 1-year mortality after hip fracture.Functional level at discharge is the main determinant of long-term mortality in patients with hip fracture. Motor FIM score at discharge is a reliable predictor of mortality and can be recommended for clinical use.

Background/Aim. Osteoporotic fractures are a major cause of morbidity in the population. Therefore, fracture prevention strategies should be a major concern, and one of the priorities in the primary health care system. The aim of the study was to assess fracture and fall risk factors, and fracture risk level in patients with acute hip fracture, and to evaluate if there had been adequate osteoporosis treatment prior to fracture in this group of patients. Methods. Fracture and fall risk factors were assessed in 342 patients, ? 65 years old, hospitalized due to acute hip fracture at the Clinic for Orthopedic Surgery and Traumatology, Clinical Centre of Serbia in a 12-month period. Fall risk factors were assessed with the Fracture Risk Assessment (FRAX?) algorithm, and patients were classified in respect to fracture risk level. Results. Hip fracture occurred in the majority of the patients in the high risk group (74.2%), where no additional bone mineral density testing was needed. Less than 10% of the patients had a diagnosis of osteoporosis before injury, while less than 2% were treated. Cognitive impairment (95.3%), visual impairment (58.2%), lower index of daily activities (51.8%), and depression (47.1%) were the most frequently observed fall risk factors. Conclusion. The results of our investigation reveal insufficient identification of clinical fracture risk factors in the primary care setting, inadequate treatment of osteoporosis and, consequently, ineffective prevention of hip fractures in the geriatric population. The introduction of FRAX? into clinical practice enables more effective acknowledgment of patients with elevated fracture risk, even if bone density measurement is not available. The results of this study have a special significance for everyday clinical practice, because they impose a need for reviewing the existing approaches to osteoporosis prevention, and precise definiment of hip prevention strategies.

Osteoarthrosis is the most frequent joint disorder in the world. An increased incidence of total hip replacement (THR) and total knee replacement (TKR) has been noticed recently. AIM: To investigate demographic characteristics, comorbidities, surgical factors and postoperative complications of patients who received THR or TKR. MATERIAL AND METHOD: Patients aged at least 30 years hospitalized at the Clinics for Orthopaedic Surgery and Traumatology, Clinical Centre of Serbia, for THR or TKR between January 1, 2008 and January 1, 2010. were included in a retrospective cohort study. RESULTS: Out of 529 investigated patients, 421 (79.6%) were in the THR group, and 108 were in the TKR group. Patients in the TKR group were 68.7+7.8 year old in average and were significantly older than patients in the THR group (p

Venous thromboembolism (VTE) is a common complication of orthopaedic surgery in the industrialised world; though there may be variability between population groups. This study aims to define the incidence and risk factors for symptomatic VTE following primary elective total hip and knee arthoplasty surgery in a single centre in Eastern Europe.This prospective study included 499 adult patients undergoing total hip and knee arthroplasty for symptomatic osteoarthritis over a two-year period at the Clinic of Orthopaedic Surgery and Traumatology, Belgrade.The overall rate of confirmed symptomatic VTE during hospitalisation was 2.6%. According to the univariate logistic regression, an age greater than 75 years (OR = 3.08; 95%CI = 1.01-9.65), a family history of VTE (OR = 6.61; 95% CI = 1.33-32.90), varicose veins (OR = 3.13; 95% CI = 1.03-9.48), and ischemic heart disease (OR = 4.93; 95% CI = 1.61-15.09) were significant risk factors for in-hospital VTE. A family history of VTE and ischemic heart disease were independent risk factors according to multivariate regression analysis. Preoperative initiation of pharmacological thromboprophylaxis (p = 0.03) and a longer duration of thromboprophylaxis (p = 0.001) were protective for postoperative DVT. Though thromboprophylaxis was safe, with very few patients suffering major haemorrhage or heparin-induced thrombocytopenia, there was a general reluctance by our local surgeons to use prolonged thromboprophylaxis.VTE is common following hip and knee arthroplasty surgery. Orthopaedic patients with a family history of VTE, heart failure and coronary heart disease are at a considerable risk of thromboembolic complications in the postoperative period. There may be a role for preoperative thromboprophylaxis in addition to prolonged postoperative treatment.

Introduction: When treating complex regional pain syndrome (CRPS) a positive outcome can be expected when the condition is identified and therapy is begun in the first six months. Nevertheless, symtpoms may not improve by standard treatment as expected. One of the possible reasons for this is the coexistence of associated compressive neuropathies in the affected hand. Case outline: A 50-year old female patient with history of CRPS on the left hand which developed as a complication of lateral epicondilytis treated with immobilization is presented. She continued to suffer from intensive pain in her hand despite pharmacological pain relief and initiation of a complex rehabilitation program. Electrophysiologic testing revealed the coexistence of conjoined severe carpal tunnel syndrome. After she underwent surgical decompression pain relief occured and overall functional results improved. Conclusion: Failure of therapy response in CRPS should alert the clinican to check for associated compressive neuropathy. Detection of this complication can prevent further damage of the nerve, hasten recovery of CRPS, and prevent eventual permanent disability of the hand.

Introduction The number of patents with dementia increases among hip fracture patients. Cognitive dysfunction is defined as a premorbid state which is potentionally negatively related to short-term functional outcome. Objective To assess the relationship between cognitive status on admission and functional gain during an early rehabilitation period in elderly hip fracture patients. Methods Forty-five elderly patients with surgically treated hip fracture were examined. Cognitive status was assessed by the Mini Mental State Examination (MMSE) at admission; functional status was assessed by the motor subscale of Functional Independence Measure (FIM) at admission and before discharge, while absolute functional gain was determined by the motor FIM gain (FIM discharge - FIM admission). Absolute functional gain was analyzed in respect to cognitive status. Results Both cognitively impaired and cognitively intact hip fracture patients exhibited overall FIM motor improvements, as well as functional gains in specific FIM motor areas (p0.05). Conclusion The systematic use of MMSE identifies cognitively impaired hip fracture patients, and effectively predicts their short-term functional outcome. A higher admission cognitive status is related to a more favorable short term rehabilitation outcome. In spite of cognitive impairment, elderly patients with hip fracture can benefit from participation in rehabilitation programmes. The systematic identification of cognitively impaired hip fracture patients at admission facilitates optimal treatment and rehabilitation, and thus enables the best achievable outcome to be reached.

Introduction: Optimal treatment of ACL (anterior cruciate injury) injuries is one of the most dynamic topics of contemporary orthopedics. Despite huge amount of publications on this subject, golden rehabilitation standard has not been established yet. Objective: The aim of our study was to compare two different rehabilitation groups in respect to dynamics and safety of recovery, and accordingly to recommend contemporary rehabilitation approach. Method: A prospective study included 45 patients with unilateral ACL rupture who were randomized into conservative (THC) and intensive rehabilitation (TH-I) group. The arthroscopic reconstruction of ACL was performed using the BTBP or STG graft. After the operation, in the TH-C group, ROM was limited to 0-0-90? and weight bearing was not allowed in the first 4 postoperative weeks. In the TH-I group, progression depended only on the knee edema and pain. The groups were compared in relation to demographic, anamnestic, and clinical characteristics (knee circumference, thigh circumference, stability tests, Lysholm, Tegner and one-leg hop test, and single stance test). Data were recorded preoperatively and postoperatively after 6 weeks, 4, 6, 9 and 12 months, and compared with parametric and non-parametric statistical tests. Results: The investigated groups clearly differed already after 6 weeks by range of motion (p