Extract
Orthopaedic rehabilitation is a subspecialty that involves the care of patients who have complex musculoskeletal problems that are often global in nature and stretch beyond the function of one joint. Rehabilitation combines biomechanics and biology in a unique manner that focuses on improving the patient’s functional outcome and overall well-being. As a result, the principles espoused by this field are relevant to every orthopaedic surgeon’s practice.
Orthopaedic rehabilitation is a subspecialty that involves the care of patients who have complex musculoskeletal problems that are often global in nature and stretch beyond the function of one joint. Rehabilitation combines biomechanics and biology in a unique manner that focuses on improving the patient’s functional outcome and overall well-being. As a result, the principles espoused by this field are relevant to every orthopaedic surgeon’s practice.
This specialty update highlights presentations and advances in several areas of orthopaedic rehabilitation discussed at meetings of the Orthopaedic Rehabilitation Association, the American Academy of Orthopaedic Surgeons (AAOS), and other specialty organizations over the past year. Notable studies and abstract presentations are also summarized.
The most intensive pediatric rehabilitation generally involves patients with neuromuscular problems. The past year was marked by renewed interest in the scientific exploration of the treatment of children with cerebral palsy.
Adolescent Crouch Gait
Adolescent crouch gait is a common form of sagittal plane gait abnormality in patients with spastic diplegia and may be defined as knee flexion contracture and a foot positioned in calcaneus during gait. It generally has gradual onset in the preteen to teenage years as the child grows. This type of gait leads to increased energy requirement, increased tibiofemoral and patellofemoral contact forces leading to knee pain, fixed knee flexion contracture, and, ultimately, the inability to walk independently1. This problem is often iatrogenic as a result of overlengthening of the gastrocnemius-soleus complex.
Vuillermin et al. reported the results of a population-based study of 464 diplegic patients (Gross Motor Function Classification System [GMFCS] level I, II, or III2) (Table I) who underwent three-dimensional gait analysis over a fifteen-year period at a single institution3. In their sample, 63% (seventeen) of the twenty-seven patients who developed crouched gait had been previously managed with a nonselective gastrocnemius-soleus lengthening. In addition, the authors found a decrease in the incidence of crouch gait from 25% to <4% in association with selective lengthening of the gastrocnemius complex with use of a modified Strayer procedure. This procedure selectively lengthens the gastrocnemius by recession at a level at which the gastrocnemius and soleus are separable. This procedure weakens the triceps surae less than more distal procedures do and produces less iatrogenic calcaneus, although it may result in undercorrection of equinus. Although this was not a randomized trial and not every patient with nonselective lengthening developed crouch gait, it was a convincing population-based study indicating that selective lengthening may be preferred for the surgical treatment of nonbraceable equinus deformity in spastic diplegic children.
Additional support for selective lengthening was provided by Dreher et al., who presented the results of a long-term follow-up study (average, 9.2 years) in which forty-four patients were managed with intramuscular aponeurotic recession by means of lengthening of the gastrocnemius followed by lengthening of the soleus if dorsiflexion was <15° in knee flexion and extension4,5. A crouched gait was observed in only 5% of the patients, although nearly 25% of the patients had recurrence of equinus and 10% had calcaneus gait without secondary crouch4. These data demonstrate the difficulty in determining and creating an appropriate amount of gastrocnemius-soleus complex lengthening in the setting of a growing child with diplegic cerebral palsy. It is evident that nonselective lengthening carries a risk of iatrogenic crouched gait, whereas selective lengthening may carry a greater risk of recurrence.
This controversy will likely continue to generate research as this type of surgery clearly assists in gait and power in other muscle groups. Davids et al. reviewed the records of fifty-three patients who had been managed with gastrocnemius-soleus lengthening and demonstrated increased strength and selective control of the antagonist pretibial muscle group in response to restoration of ankle dorsiflexion range of motion6. This finding is not surprising as the pretibial muscles function in an overlengthened position (and are therefore weakened) in the presence of fixed equinus contracture. Notably, this group performed selective lengthening or nonselective lengthening on the basis of the magnitude of the fixed contracture on physical examination.
Hip Displacement in Cerebral Palsy
Spastic hip displacement is a very common problem in patients with cerebral palsy, especially in those with greater degrees of neurologic impairment (GMFCS levels IV and V)7. The prevalence of hip displacement may be higher than one-third in patients who are at GMFCS level III, IV, or V7. Hip displacement may be associated with problems such as difficulties with positioning/seating, and a subset of patients may develop painful arthritis with a chronically dislocated hip. There has been great interest in early screening and treatment, with the goal of preventing the need for reconstructive or salvage surgical procedures in children with more advanced disease. A population-based study from Sweden and Norway demonstrated that such a surveillance program may reduce the total number of surgical procedures performed and that surgical interventions (when required) were performed at an earlier age7.
While early soft-tissue releases (adductor lengthening with or without psoas lengthening) have been advocated as preventive surgery for patients with fixed hip contractures who have not developed substantial osseous dysplasia, the most common reconstructive procedure for patients with established osseous dysplasia includes a femoral varus derotational osteotomy with or without a volume-reducing pelvic osteotomy. A variety of salvage options have been described to treat the chronically painful dislocated hip.
With regard to early soft-tissue releases, Shore et al. performed a survival analysis of 330 patients (all GMFCS levels) with spastic cerebral palsy and hip dislocation who were managed with adductor releases (with iliopsoas release being performed in nonambulatory patients with hip flexion contracture of >20°) and found that the risk of failure was heavily dependent on GMFCS level8. Failure was defined as a migration percentage >50% or subsequent surgery to address hip displacement. Nearly 50% of GMFCS level-III patients and >75% of GMFCS level-IV and V patients had a failure of soft-tissue surgery. The mean time to failure was four years, and the mean age at the time of failure was 8.4 years. Although these results in patients with more advanced disease are discouraging, adductor surgery may have a role in delaying osseous surgery and decreasing the need for later surgical procedures.
Huh et al. performed a retrospective review of reconstructive surgery in seventy-five patients and found no significant difference between femoral-sided surgery and combined femoral and pelvic surgery with regard to recurrent subluxation or dislocation when the senior author’s intraoperative judgment was used9. The authors found that isolated femoral varus derotational osteotomy and adductor release can be performed if adequate femoral head coverage is noted on fluoroscopy following these interventions but that additional pelvic osteotomies and/or open reduction should be performed if fluoroscopy reveals suboptimal coverage following femoral varus derotational osteotomy. Additionally, they showed that an increased migration percentage (>50%) at the time of surgery and a lower functional level (a higher GMFCS class) were more likely to be treated with combined surgery. These findings are contrary to those of previous reports that recommended both femoral and acetabular-sided hip surgery in the setting of cerebral palsy and hip displacement10. Additional research may elucidate which is more appropriate in a given scenario.
Stiff Knee Gait
Stiff knee gait is commonly due to spasticity of the rectus femoris muscle and presents as a loss of knee flexion during swing phase due to continuous or out-of-phase activity of this muscle. This entity may occur in children with cerebral palsy or in adults with stroke or brain injury. Stiff knee gait impairs foot clearance during swing phase and often results in tripping and falling. While rectus femoris transfer has been commonly performed, some have advocated simple release of the tendon. Presedo et al. reported on a series of forty-five patients with cerebral palsy who underwent distal excision of a segment of the rectus femoris tendon, with resolution of stiff knee gait at two years of follow-up11. Previous studies had not demonstrated a similar conclusion, and Presedo et al. suggested that these discouraging results might be due to pseudotendon formation after release rather than excision11. Alternatively, Thawrani et al. evaluated the results of a rectus transfer procedure in patients with cerebral palsy and a stiff knee gait and reported an improvement in gait parameters at the time of intermediate and long-term follow-up12. We noted similar results in an adult population at our institution13. Direct comparison of these techniques with the appropriate research protocol would further illuminate the role of each type of surgery.
Instrumented motion analysis affords a detailed analysis of locomotion and can be very helpful for the evaluation of patients with complex upper and lower-extremity movement disorders. The routine use of instrumented motion analysis in ambulatory patients with cerebral palsy continues to be debated, partly because of inconsistencies in the end point of measurement. While such a sophisticated analysis may characterize a patient’s gait in detail, treatment decisions are ultimately made by the surgeon in discussion with family members and other consultants and may be further refined by the examination with the patient under anesthesia. As such, studies that attempt to define the usefulness of instrumented motion analysis by correlating motion laboratory findings with the final interventions performed may show considerable variability. In addition, motion analysis laboratories are both cost and personnel-intensive and their advantages should be tested and proven in a study-specific manner.
Kim et al. performed an inter-rater reliability analysis in a study involving ninety-one ambulatory patients with spastic diplegia (GMFCS levels I, II, and III) in which observational gait analysis was compared between an experienced rater and a novice rater (a resident) with use of instrumented motion analysis as a control14. The authors found that an experienced rater was able to reliably15 classify the gait patterns (into equinus, apparent equinus, crouch gait, and jump gait) in a similar fashion to the computer software (kappa = 0.67), whereas a novice rater was not able to reliably classify the gait patterns (kappa = 0.37)14. Although a dynamic gait study is helpful for defining a patient’s problem list when available, there are many settings in which such a study cannot be performed.
Instrumented motion analysis studies have also been useful for analyzing outcomes in neurologically normal, even athletic populations. Giphart et al. used three-dimensional motion analysis and biplanar fluoroscopy to study the effects of tenodesis of the long head of the biceps on glenohumeral kinematics in five patients who were managed with open subpectoral tenodesis of the long head of the biceps tendon16. The authors examined the involved limb and compared it with the uninvolved, contralateral limb during shoulder abduction and the late cocking phase of throwing. The investigators noted a <1-mm position difference in terms of translation between tenodesed and nontenodesed shoulders16. These findings are important because they indicate that biceps tenodesis does not result in clinically important changes in glenohumeral biomechanics during throwing and other activities.
Brandon et al. performed a study of nine males with use of electromyographic analysis, electrogoniometry, and a position transducer to characterize motion involving a barbell squat17. They found that kinematics could be accurately represented by electrogoniometry alone as the motion analysis of the barbell was highly correlated with electrogoniometry readings. The study also confirmed the reliability of the three components of the test that was used for this particular exercise, which lays the foundation for additional study of variability, which could potentially be a source of injury or injury prevention for strength-training athletes.
The increased energy expenditure associated with higher-level lower-extremity amputation is well recognized18. Mohanty et al., in a study of thirty transtibial amputees, compared the energy cost of walking between prosthetic walking and walking with crutches and no prosthesis19. The authors noted a 21% increase in energy expenditure when walking with crutches without a prosthesis was compared with walking with a prosthesis19. In addition to issues of body image, that study highlighted the importance of planning for and obtaining a permanent prosthesis for these patients as “crutches without prosthesis” may be an energy-inefficient solution19.
Many of the technological advances in upper extremity prostheses involve considerable patient commitment. Jönsson et al. described an intriguing procedure in which a titanium fixture is surgically attached to the skeleton and then a skin-penetrating abutment is attached to the prosthesis itself20. The advantages of this procedure may include greater stability and freedom of motion20. Clearly, concerns regarding infection and loosening over time exist; however, progress in upper extremity prostheses is very encouraging. This is particularly true in light of the study by Jang et al., who performed a survey of 307 upper extremity amputees and reported that >80% of the respondents used the prosthesis for cosmesis only and that fewer than half used the prosthesis for more than eight hours per day21. Almost 70% of the patients changed their job or became unemployed following the amputation because of functional impairment. As upper extremity amputations are increasingly common in association with war wounds, upper extremity prosthetic technology will become increasingly important.
With regard to limb salvage, Patzkowski et al., in conjunction with the Skeletal Trauma Research Consortium, performed a randomized crossover performance trial in which an energy-storing orthosis (the Intrepid Dynamic Exoskeletal Orthosis) was compared with three commercially available orthoses in eighteen patients with unilateral dorsiflexion or plantar flexion weakness (strength, <4 of 5) from a variety of causes22. The energy-storing orthosis improved speed during running as well as stair-climbing and walking on uneven surfaces. Most importantly, eight of thirteen patients who were considering amputation ultimately chose limb salvage with this new orthotic option after completion of the clinical pathway. This encouraging finding suggests that limb salvage may be a more attractive option for selected high-demand patients because of the availability of an energy-storing orthosis.
Heterotopic ossification is a challenging problem, and the physiologic basis of this disorder remains elusive. Heterotopic bone occurs as a sequela of tissue trauma and is more common in the neurologically impaired population. Davis et al. compared muscle biopsy specimens from thirty-one combat blast injury victims with those from six normal controls who were undergoing hamstring autograft anterior cruciate ligament reconstruction23. The authors performed reverse polymerase chain reaction analysis and found that injured tissue had more cell lines devoted to connective tissue lineage. Additionally, the blast injuries that ultimately were associated with the development of heterotopic ossification had more cells of an osteogenic lineage. This study provides a fascinating basis on which to develop prognostic tests for the development of heterotopic bone following trauma.
Advancements have been made in understanding the cellular basis for the formation of heterotopic ossification, which generally follows the endochondral bone formation pathway seen in normal bone formation. The distinguishing feature of heterotopic ossification is the requirement for tissue damage as a prerequisite. This finding has identified vascular endothelium as the primary focus of research24,25. Despite this finding, Wosczyna et al., in an in vivo study of mice, showed that vascular endothelium does not participate in bone morphogenetic protein (BMP)-2-mediated osteogenesis at levels that normally would be expected to produce a vigorous osteogenic response26. The investigators found a population of mesenchymal pluripotent cells that possess receptors capable of osteogenic differentiation and theorized that the presence of local osteogenic factors (such as BMP) leads to a transformation of these cells into an osteogenic lineage, resulting in the clinical manifestation of heterotopic ossification. It remains to be seen whether these cells are exclusive to the murine population or if the result is reproducible in a human population.
Additional clinical data on the resection of heterotopic ossification were also reported by Fuller et al.27. Those authors retrospectively reviewed the records of ten patients (eleven shoulders) with traumatic brain injury who underwent excision of heterotopic ossification around the shoulder. Nine of the ten patients also had direct elbow trauma, and the tenth patient had bilateral involvement but had no history of direct shoulder trauma. All patients had recovered sufficiently from the initial injury to tolerate surgery and to participate in a postoperative rehabilitation program. The indications for surgery included pain and restriction of range of motion and/or function. The authors found gains in sagittal, coronal, and axial plane motion at an average of 46.5 months of follow-up. Furthermore, the patients were able to perform additional functional activities (hand to mouth, hand to perineum, hand to head). No patient declined functionally. The authors also found that three of the ten patients had a recurrence, one patient had painless acromioclavicular joint instability, and one patient had humeral head osteonecrosis that required hemiarthroplasty.
Patients with spinal cord injuries require ongoing rehabilitation and medical care to promote maximum functionality. These needs place tremendous strain on the health-care system in terms of cost and work force28. Kim et al. performed a survey study on the possibility of telerehabilitation in this population28. Telerehabilitation is the application of technology to provide distance support, assessment, and intervention to individuals with disabilities or rehabilitation needs and can bridge the gap between clinical encounters and provide instantaneous feedback to a patient in terms of clinical care28,29. Telerehabilitation holds particular promise for individuals who live in remote or underserved areas. The ability to deliver rehabilitation services to remote areas is critical because the impairments acquired by individuals in remote areas can result in permanent disability or loss of function because of the lack of appropriate rehabilitation28-31. Kim and colleagues interviewed thirty-six health-care professionals who were very involved in the care of patients with spinal cord injuries and fifty-seven patients who had such injuries28. The groups were in agreement that telerehabilitation could be helpful for patients who need help with activities of daily living, ongoing rehabilitation needs, and health monitoring. This is an intriguing idea and could provide cost-effective care for this health care-intense population.
Retention of upper extremity function is vitally important for preserving function and independent living in tetraplegic patients. Wangdell and Fridén reported on the results of reconstruction of elbow extension function with use of a deltoid-to-triceps transfer32. The authors evaluated fourteen patients (nineteen arms) with use of the Canadian Occupational Performance Measure at twelve months after surgery32. Over the first twelve months, patients had the most improvements in writing and stretching the arm out while lying down. Patients made the smallest gains in driving a wheelchair and transfers. Longer-term follow-up and rehabilitation may lead to improvement in the results as the authors noted that the results continued to improve with time. This problem remains without a reliable solution and is an area of further research and innovation.
The 2012 Jacquelin Perry Award went to Dr. Addisu Mesfin. Mesfin et al. explored the Rehabilitation section of the Orthopaedic In-Training Examination (OITE)33. They provided an analysis of the OITE for the years 2004 to 2009 focused on content, taxonomy, mean score, and references cited. Overall for the five-year period, 3.3% of the overall examination focused on rehabilitation. Of the fifty-three questions from those years, 20.8% dealt with prosthetics/orthotics, 20.8% dealt with neuro-orthopaedics, and 18.9% dealt with physical therapy treatment and outcomes. The remainder dealt with rehabilitation terminology and spinal cord injury. Over half of the questions were simple recall, one-third dealt with development of a treatment plan, and the remainder dealt with diagnosis. The mean score in the Rehabilitation section was 54.1%.
Many original scientific papers and reviews of current concepts were presented at the Orthopaedic Rehabilitation Association Specialty Day at the 2012 meeting of the AAOS in San Francisco, California, with an emphasis on the rehabilitation of upper extremity conditions.
A major focus of this year’s meeting was advances surrounding transplantation of the hand and upper extremity. Composite tissue transfer is not a new concept. Peacock, in 1957, performed what is believed to be the first composite tissue allograft of an en bloc digital flexor mechanism transplant34. This transplant was performed without the aid of immunosuppression or microsurgery and was thought to be reconstituted after transplantation by microvascular pathways of the recipient. Peacock was able to perform this technique with use of data from his early animal models, which demonstrated a low antigenicity of these tissues35. The first known attempt at hand transplantation was in 1964 by Gilbert36. The operation was technically successful, and the patient was managed with azathioprine and prednisone as anti-rejection measures. Unfortunately, the patient experienced acute rejection and underwent revision amputation in less than three weeks. The journey from failure to success would take more than thirty years. Dubernard et al. performed the first successful hand transplant in 199837. Much of the success in that case was due to improvements in both surgical technique (microvascular surgery) and medical therapy (improvements in immunosuppression). The major goals of this reconstructive community would ultimately be to perform hand transplantation, to optimize patient function postoperatively, and to minimize immunosuppression with its concomitant risks37.
Functionally, a major issue of hand transplantation continues to be reinnervation of the extremity. Motor and sensory recovery following surgery is unpredictable38. It is also unclear whether the actual recovery is due to patient-related factors, technical factors, or postoperative protocol. However, hand transplantation surgery continues to be a frontier in orthopaedic and microvascular surgery because of the disability caused by upper extremity loss. The procedure remains a cutting-edge procedure, and the cost of failure is extremely high (upwards of three million dollars)39.
Other topics related to the upper extremity were also explored. Baldwin and Lee presented a systematic review of the treatment of symptomatic upper extremity heterotopic ossification40. The majority of cases involved elbows. The authors identified sixty-six qualifying studies with a total of 1119 elbows. In this group of 1119 elbows, heterotopic ossification was associated with trauma (35.2%), brain injury (33%), burns (21.5%), operative treatment (6.5%), and a combination of etiologies (2.6%). In terms of diagnostics, radiographs were routinely used. The use of computed tomography (CT) was advocated in 21.2% of the studies and was particularly useful when the heterotopic ossification was close to vital structures. Bone scans were used in 10.6% of the studies, mostly to determine the maturity of the heterotopic ossification, but were of limited value. For heterotopic ossification of the elbow, determination of the effectiveness of prophylaxis was difficult because of the different doses, different regimens, and different timing among studies. There was no significant difference between patients with and without prophylaxis in terms of the final range of motion or recurrence. Overall, the range of motion of the elbow increased in all patients, by a mean of 71.6°, from baseline to the latest follow-up (with an average preoperative flexion-extension range of 53.3° to 83.0°, compared with an average postoperative range of 22.3° to 122.3°). Brain injury patients and patients with a combined etiology had the smallest gain in motion (average, 69.4°), and burn patients had the greatest gain in motion (average, 84.4°). The complication rate for all studies (including recurrence, infection, nerve and vessel injury, hematoma, and dehiscence) was 17.5%.
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