The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 91, Issue 9

Specialty Update | September 01, 2009

What's New in Orthopaedic Rehabilitation

Harish Hosalkar, MD, MBMS(Orth), FCPS(Orth), DNB(Orth)¹; Nirav K. Pandya, MD²; Jason Hsu, MD²; Mary Ann Keenan, MD²

¹ Rady Children's Hospital, UCSD San Diego, 3030 Children's Way, Suite 410, San Diego, CA 92123. E-mail address: HHosalkar@rchsd.org
² Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Two Silverstein, Philadelphia, PA 19104. E-mail address for M.A. Keenan: maryann.keenan@uphs.upenn.edu

View Disclosures and Other Information

Specialty Update has been developed in collaboration with the Council of Musculoskeletal Specialty Societies (COMSS) of the American Academy of Orthopaedic Surgeons.

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from a commercial entity ($1500 Honorarium from JBJS to Dr. Hosalkar for prior Orthopaedic Rehabilitation Update).

The Journal of Bone and Joint Surgery, Inc.

J Bone Joint Surg Am, 2009 Sep 01;91(9):2296-2310. doi: 10.2106/JBJS.I.00319

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Extract

Orthopaedic rehabilitation involves the care of patients who have complex musculoskeletal problems that are global in nature rather than being limited to one or two anatomic locations. It is a specialty that combines biomechanics and biology in a unique manner with an approach that focuses on improving the functional outcome for individuals with musculoskeletal disability through surgical and nonsurgical management.

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Introduction

This specialty encompasses patients of all ages, a broad range of anatomic locations, and a variety of musculoskeletal dysfunctions. Orthopaedic rehabilitation comprises all of the traditional orthopaedic subspecialties, including amputation surgery, prosthetic and orthotic management, neuromuscular diseases, and a variety of other neurologic disorders, with a focus on the musculoskeletal system as a whole as well as on the linkages and couplings between bones, joints, muscles, and the nervous system.

This specialty update highlights presentations and advances in several areas of orthopaedic rehabilitation in recent times. Some abstracts of notable studies in this area of expertise are also succinctly summarized.

Motion Analysis and Dynamic Electromyography

Gait analysis and dynamic electromyography are two essential tools that are utilized by physicians who deal with both the operative and nonoperative aspects of motion disorders. These modalities allow not only for the diagnosis of pathologic conditions but also for a deeper understanding of normal mechanics and functional anatomy. Research that stems from laboratories utilizing these techniques has allowed for a better understanding of both the need for and the outcomes of interventions (surgical and nonsurgical) that help to facilitate normal gait and muscle function. There have been multiple excellent studies in this area of investigation within the past year.

One of the dilemmas faced by physicians is the ability to standardize the data that they receive from different motion-analysis laboratories. How uniform are the protocols and results from different sites? Gorton et al.¹ examined the kinematic variability among twelve motion-analysis laboratories. They analyzed four sources of variability (examiners, trials, systems, and days), and they also recorded the change in variability following the implementation of a standardized gait-analysis protocol. At each of the twelve different sites after an initial day of instrumentation/calibration, the same single healthy subject was evaluated for six consecutive days while engaging in five kinematic trials examining pelvic tilt, pelvic obliquity, pelvic rotation, hip flexion, hip abduction, hip rotation, knee flexion, ankle dorsiflexion, and foot progression angle. After all trials were completed at a particular site, a minimum standardized gait-analysis protocol was implemented, and the same subject returned to each laboratory within a three-month period (one year after the first set of kinematic evaluations) for repeat testing. The authors found that without a standardized protocol, >75% of the overall variance in measurements could not be attributed to the system (motion capture), between days, or within sessions. The most likely etiology of the variance was the examiners, particularly with regard to where the markers were being placed on the patients. After implementation of the minimum standardized gait-analysis protocol, there was a 20% decrease in the standard deviation of all of the kinematic measures except pelvic tilt and hip rotation (which had increases of 4% to 8% after implementation of the minimum standardized gait-analysis protocol). Furthermore, after implementation of the minimum standardized gait-analysis protocol, the range of values between examiners decreased in all measures by an average of 29%, with only hip rotation showing an increase of 19% in its range of values. The authors concluded that the most effective way to standardize kinematic measurements between motion-analysis laboratories is to standardize the manner in which examiners place markers on their patients for motion analysis. The results of that study suggest that motion-analysis laboratories should implement a minimum standard gait-analysis protocol such as that utilized by Gorton et al. so that patient data can be more reliably and accurately combined from different sites. Training programs should be developed to promote uniform marker placement to reduce errors between examiners and motion-analysis laboratories.

Stewart et al.² examined the action of the hamstring muscles during standing in crouch to better understand the crouch gait pattern of patients with cerebral palsy. In an investigation involving five healthy control subjects, the authors utilized functional electrical stimulation to produce muscle contraction/stimulation while the subjects stood in the crouch position with one foot on a force platform as well as with both feet flat on the ground. Subjects stood in a range of postures with varying degrees (0°, 10°, 20°, 30°, 40°, 60°, and 80°) of knee flexion. The hamstrings were stimulated for one second with the functional electrical stimulation system, and the resulting movements were recorded. The authors found that the hamstrings had a retroverting effect on the pelvis at all degrees of knee flexion while they served to extend the hip. This finding suggests that in a patient with cerebral palsy with excessive anterior pelvic tilt, the hamstring muscles can combat this deformity. At the knee, the hamstring muscles were shown to act as knee flexors at low knee flexion, but as knee flexion increased to a position of crouch, the hamstrings displayed activity as knee extensors. This finding was due to the fact that the hamstring moment of the knee was shown to be the net effect of two competing forces: the moment arm at the knee, promoting crouch, and the moment arm at the hip, promoting extension. This suggests that the hamstrings initiate knee flexion from a neutral standing position. The hamstrings do not contribute to increased crouch at higher knee flexion angles. At high flexion angles, the hamstrings appear to combat knee flexion by promoting hip extension.

The clinical implications of that study suggest that excessive hamstring force at the knee is unlikely to cause increased crouch. Rather, weakness of the hamstrings as hip extensors is more likely to be responsible for increased crouch. During neutral standing, the hamstring action leads to pelvic retroversion, hip extension, knee flexion, and ankle dorsiflexion. As subjects are increasingly positioned in crouch (increased knee flexion), the hamstrings continue to retrovert the pelvis and extend the hip, yet they change from flexors to extenders of the knee joint. These findings are important for the development of surgical interventions for patients with cerebral palsy who have crouch gait. The authors recognized that additional study is necessary to specifically examine the gait of patients with cerebral palsy and to analyze their gait in a more dynamic fashion.

Reinbolt et al.³ further examined gait abnormalities that are commonly seen in patients with cerebral palsy in a study examining the activity of the rectus femoris in stiff-knee gait. Stiff-knee gait is characterized by diminished knee motion and delayed peak knee flexion during swing and is usually attributed to abnormal prolongation of the rectus femoris into early swing. Rectus femoris transfer surgery is utilized to decrease the muscle's ability to extend the knee while maintaining its ability to generate a hip flexion moment. Because of varying outcomes in association with this procedure, the authors sought to determine the importance of pre-swing (prior to toe-off) rectus femoris activity (rather than early swing activity) as a contributor to decreased knee flexion in subjects with a stiff-knee gait. They examined the results of gait analysis for ten patients with cerebral palsy who had a stiff-knee gait prior to the performance of a rectus femoris transfer. None of these patients used orthoses or assistive devices. They also evaluated fifteen healthy control subjects. The gait-analysis data, including three-dimensional joint angles, ground-reaction forces and moments, and surface electromyography recordings, were then utilized to create a muscle-actuated dynamic simulation of each subject in which the rectus femoris activity was eliminated during pre-swing, and separately during early swing, to determine resulting changes in knee flexion based on muscle elimination.

The authors found that peak knee flexion increased more (7.5° ± 3.1° compared with 4.7° ± 3.6°; p = 0.035) when the rectus was eliminated during pre-swing rather than during early swing. Six subjects noted an increase in knee flexion that was 90% higher for the pre-swing elimination of rectus activity than for the early-swing elimination, three subjects noted an increase in knee flexion (within 10%) that was similar for both cases, and one subject noted a 37% decrease in knee flexion with pre-swing elimination. Given these results, the authors concluded that pre-swing rectus femoris activity is as important as early-swing activity. Furthermore, for some subjects, pre-swing rectus femoris activity may actually limit knee flexion more than early-swing activity does. The authors suggested that pre-swing muscle forces generate the initial conditions for swing phase (by increasing knee flexion velocity at toe-off) and that excessive rectus force during double-limb stance may decrease knee velocity at toe-off and lead to a stiff-knee gait. That study is important for the surgeon who is planning an intervention for the treatment of a stiff-knee gait as both early-swing and pre-swing electromyography activity should be studied. In addition, the muscle-actuated dynamic simulation used in that study is a valuable tool for understanding the biomechanical forces underlying pathologic gait by allowing the selective elimination of muscle activity.

Impaired walking is a major problem faced by patients who have had a stroke, and inpatient and intensive outpatient therapy has been successful for improving the gait of these patients. Dunsky et al.⁴ examined the problems with gait rehabilitation that patients face when they return home after a stroke, specifically, the inability to integrate intensive gait practice in a home-based therapy program because of the space, facilities, and personnel that are available. In particular, Dunsky et al. examined the use of home-based motor imagery training as a rehabilitation tool for gait rehabilitation in individuals who have had a stroke. Motor imagery is a cognitive operation that allows for improved performance of certain tasks through the repetition of motor scenes and routines by means of imagery^4,5. The purpose of the study was to confirm if home-based motor imagery training would improve walking speed and kinematic variables in individuals who were in the chronic phase of rehabilitation after a stroke. Seventeen patients with hemiparesis stemming from a stroke participated in the study, which involved six weeks of home-based motor imagery training provided by the same person in the patient's home and five laboratory sessions (two before the start of imagery training, one at intermediate term, one at the end of imagery training, and one at three weeks after the end of training). Spatiotemporal and kinematic gait parameters, including stride length, step length, single and double-support times, and ankle and knee ranges of motion, were measured with use of motion and gait-analysis systems. In addition, clinical and functional gait assessment was performed with use of the gait portion of the Tinetti Performance Oriented Mobility Assessment and the Modified Functional Walking Categories Index. A full detailed description of the motor imagery training appears in the article⁴.

The authors found that after motor imagery training, mean gait speed increased and was maintained at the time of the latest follow-up, stride length increased by 18%, paretic step length improved by 15%, nonparetic step length improved by 16%, and average cadence increased by 8%. Furthermore, sagittal knee range of motion of the paretic joint improved by 18%. There were no significant changes in range of motion of the ankle. There was also a 10% improvement in gait symmetry, mainly because of a 13% increase in the paretic single limb-support period. There was no significant change in the paretic limb-support period, concomitant with a 10% decrease in the double limb-support period. In addition, there was a 3-point improvement on the gait scale of the Performance Oriented Mobility Assessment in fourteen of the seventeen participants and a one-category improvement in walking independence as measured with the Modified Functional Walking Categories Index in eleven patients. The overall effect size of the motor imagery was highest for stride length (0.759), followed by nonparetic step length, paretic step length, and walking speed. Gait symmetry was the least-affected variable.

The authors concluded that although additional study is necessary, home-based motor imagery exercises can improve walking skills for patients with hemiparesis after a stroke. A future study comparing imagery training with no intervention as well as with non-imagery-based gait rehabilitation courses is necessary. Yet, the study described above gives hope to the patient who has had a stroke who can no longer participate in out-of-home, intensive gait rehabilitation, allowing for possible improvement in gait while at home with use of motor imagery.

Amputation Surgery and Prosthetics

Technological advances have continued to lead to vastly improved prostheses for patients who have undergone amputation. With the changing nature of military combat, there have been an increasing number of young men and women who have sustained traumatic amputations. This has led to increased interest and research in the development of upper and lower extremity prostheses. Yet, even with this technological drive, the key literature from the past year with regard to amputations and prosthetics has centered on traditional amputation/prosthetic techniques, patient pain, and the psychological effects of undergoing an amputation and/or wearing a prosthesis.

Distal tibiofibular bone bridging in patients with transtibial amputation has become a recent area of interest, although similar techniques were described as early as World War I⁶. Strong proponents of the technique argue that the creation of the bone bridge allows for direct end bearing. Those who are more moderate believe that although the technique increases the surface area for distributing mechanical load and prevents pain resulting from pathologic motion of the fibula, it should be reserved for young, active amputees who would benefit from a better terminal weight-bearing surface (which would offset the morbidity from additional surgery)⁷. Pinzur et al.⁷ examined a series of twenty consecutive patients who had a unilateral transtibial amputation as a result of trauma who also underwent distal tibiofibular bone bridging. These patients were compared with a historical control group of fifteen highly functional, American control patients with a transtibial amputation who had not undergone the bone bridging as well as a historical group of thirty-two Brazilian patients who had undergone a transtibial amputation with distal tibiofibular bone bridging in their home country. The groups were compared with regard to their scores on the Prosthesis Evaluation Questionnaire, a validated outcomes measure that measures the effect of lower extremity amputation on quality of life. The authors found that the Prosthesis Evaluation Questionnaire scores in the American bone-bridging group were similar to those in the American control group. Both American groups scored lower than the Brazilian bone-bridging group in the social burden, ambulation, frustration, sounds, utility, and well-being domains of the Prosthesis Evaluation Questionnaire.

The results of that study indicate that distal tibiofibular bone bridging may not lead to improved outcomes, particularly when it requires an additional operation. That study also further highlights the need for prospective studies that not only can examine the bone-bridging technique, but, more importantly, can facilitate further understanding of the residual limb as an end-bearing surface in patients with transtibial amputation.

Following transtibial amputation, various types of rigid (i.e., plaster-of-Paris), semi-rigid, and soft dressings have been used to facilitate rapid prosthetic fitting and rehabilitation. Rigid plaster-of-Paris dressings have been used for many years to control volume and to prevent edema, yet many surgeons continue to use soft dressings because they are easier to apply, allow access to wounds, and prevent pressure ulcers. Johannesson et al.⁸ examined a vacuum-formed removable rigid dressing that potentially could provide the benefits of a rigid plaster-of-Paris dressing while at the same time allowing wound access and ease of application. Twenty-seven patients undergoing transtibial amputation because of peripheral vascular disease were randomized to receive either a conventional rigid dressing or the vacuum-formed rigid dressing for five to seven days postoperatively, followed by compression therapy with use of a silicone liner. Outcome measures included time to prosthetic fitting and function with the prosthesis at three months postoperatively. Twenty-three patients (thirteen of fifteen in the vacuum-formed group and ten of twelve in the traditional plaster-of-Paris group) achieved prosthetic fitting at three months. Three patients were unable to achieve prosthetic fitting because of early death related to the medical conditions, and one patient in the plaster-of-Paris group had development of a 45° flexion contracture of the hip and knee and was unable to be fitted for a prosthesis. There was no difference between the two dressings with regard to the rate of wound complications or the time to prosthetic fitting (thirty-seven days in the vacuum-formed group, compared with thirty-four days in the plaster-of-Paris group). Furthermore, there were no significant differences between the two groups with regard to function with the prosthesis.

The results of that study suggest that the vacuum-formed rigid dressing can provide results similar to those provided by a conventional rigid plaster-of-Paris dressing in the immediate postoperative period for patients undergoing transtibial amputation with regard to time to prosthetic fitting and function with the prosthesis, while still allowing access to the wound and ease of application. Additional study is necessary to investigate the cost-effectiveness of this new technology, its applications in other patient populations (patients without peripheral vascular disease), and how the outcomes compare with those associated with soft dressings.

Although the orthopaedic community has spent the majority of its time on the technical aspects of amputation, two recent studies examined the development and treatment of pain that the amputee experiences postoperatively, one of the major clinical complaints that the orthopaedic surgeon has to address postoperatively. Schley et al.⁹ examined the potential mechanisms for the development and origin of phantom-limb pain in a study of ninety-six upper limb amputees (all but one of whom had undergone an amputation because of a traumatic injury). Using a questionnaire, they assessed pre-amputation pain and the presence or absence of phantom pain, phantom sensation, stump pain, and stump sensation. The median duration of follow-up in the study was 3.2 years. The authors reported stump sensation to be the most prevalent finding in their cohort (78.5%), followed by stump pain (61.5%), phantom sensation (53.8%), and phantom pain (44.6%). Phantom pain decreased in only 48.2% of the patients and either remained stable or worsened in the remainder. A similar finding was found for stump pain, with only 47.5% of the patients noting reduction in the pain at the time of the questionnaire. Interestingly, phantom pain occurred immediately after amputation in only 28% of the amputees, within one year in 10%, and after one year in 41%. The authors concluded that stump pain/sensation is the initial predominating source of patient discomfort and that phantom pain/sensation is a long-term consequence (with some patients noting an onset almost a year after surgery).

That study indicates that clinicians must be fluid in their use of pain-relieving measures after amputation, dealing with stump pain/sensation initially and then focusing their efforts on phantom pain/sensation at a later time with different modalities and pharmacologic measures. Furthermore, that study demonstrates that a more nuanced approach to postoperative pain after amputation must be taken (by not simply grouping all pain as "phantom" pain) and shows that phantom pain may appear much later than originally thought and may be a challenge to treat or alleviate.

In the same light, Wilson et al.¹⁰ examined modalities that potentially could be used to deal with persistent pain after lower extremity amputation; specifically, they performed a double-blind, randomized trial evaluating the effect of ketamine on pain and sensory processing after amputation. Fifty-three patients who were undergoing lower limb amputation participated in the study. After receiving a combined intrathecal-epidural anesthetic for surgery, patients either received an epidural infusion of racemic ketamine and bupivacaine (group K) or saline solution and bupivacaine (group S). No other analgesics were allowed in the postoperative period (ranging from forty-eight to seventy-two hours) except the epidural infusions. Pain characteristics were assessed for twelve months after surgery, with a specific focus on the prevalence and severity of postoperative pain. In the immediate postoperative period while the epidural anesthetic was being infused, the patients receiving ketamine and bupivacaine (group K) had significantly lower pain scores than those receiving saline solution and bupivacaine (group S). After discontinuation of the epidural anesthetic until the time of the one-year follow-up, the rates of stump and phantom pain did not differ between the two groups (21% and 50%, respectively, for group K, compared with 33% and 40%, respectively, for group S). Interestingly, the levels of depression and anxiety were found to decrease significantly in group K during the course of the study, whereas a similar decrease was not seen in group S.

The results of that study suggest that epidural infusions of ketamine combined with bupivacaine may be of value for the control of post-amputation pain in the immediate postoperative period. Furthermore, ketamine may have a potential effect on decreasing postoperative levels of depression and anxiety; this observation requires additional study.

That study highlights another major battle that amputees face in the postoperative period: depression and anxiety over the loss of the limb. Singh et al.¹¹ examined the course of symptoms of depression and anxiety after amputation during inpatient rehabilitation. One hundred and five patients who were admitted to inpatient rehabilitation following a lower limb amputation were examined. The Hospital Anxiety and Depression Scale was utilized to assess symptoms of anxiety and depression at the times of admission and discharge, and these symptoms were correlated with demographic and patient features, including the level of amputation, the success of limb-fitting, age, and sex. At the time of admission, 26.7% of the patients had symptoms of depression and 24.8% had anxiety; these values decreased significantly to 3.8% and 4.8%, respectively, at the time of discharge (at a mean of 54.3 days later). Patients who had higher levels of depression and anxiety required longer inpatient rehabilitation stays, and patients with depression were more likely to have other medical comorbidities or to live in isolation. The level of amputation, the success of limb-fitting, age, and sex were not associated with the failure of these symptoms to resolve.

The results of that study indicate that postoperative depression and anxiety can resolve more rapidly (in a period of nearly two months) than what was previously thought (in a period of several years). This finding indicates that, during the immediate postoperative course, inpatient rehabilitation should be focused on teaching the patient skills that can improve his or her function at the time of discharge as the symptoms of depression and anxiety will rapidly resolve even in patients who are in severe distress. Furthermore, patients at greater risk for post-amputation depression (those who have medical comorbidities or who are living alone) can be identified, and additional support can be given to them both preoperatively and postoperatively.

Pediatric Neurology

Pediatric orthopaedic surgeons commonly deal with the musculoskeletal manifestations of cerebral palsy, working closely in a multidisciplinary fashion with pediatricians, neurologists, and therapists. Over the past year, several excellent studies in this area have examined the use of botulinum toxin and baclofen, the outcomes of surgical interventions in this patient population, and bracing as it affects gait.

Yang et al.¹² examined the effects of botulinum toxin type A on hip subluxation in patients with cerebral palsy. That study retrospectively compared three different groups of patients: (1) a control group of patients who did not undergo any intervention, (2) a group of patients who underwent soft-tissue surgery on the adductor muscles, and (3) a group of patients who received botulinum toxin type A injection into the hip adductor muscles. One hundred and ninety-four patients with cerebral palsy were enrolled in the study. The Reimers hip migration percentage was utilized to measure the degree of hip subluxation on pelvic radiographs annually. The authors found that the overall annual change in the Reimers hip migration percentage improved in both the soft-tissue surgery group (-1.6% ± 4.4%) and the botulinum group (-0.7% ± 6.5%), whereas it worsened in the control group (4.4% ± 11.3%). The differences between the intervention groups and the control group were significant, although there was not a significant difference between the botulinum and soft-tissue-surgery groups. Furthermore, the authors found that several subcohorts of patients were more likely to benefit from either of the interventions (botulinum toxin type A or soft-tissue surgery), including patients younger than three years of age, higher-functioning patients, and patients with moderately subluxated hips. Future prospective studies examining botulinum toxin type A as compared with soft-tissue surgery (as well as combinations thereof) may lead to a viable nonsurgical treatment or improved surgical outcomes with combined measures in these patients.

Continuing in the study of pharmacologic agents effecting a change in patients with cerebral palsy, Shilt et al.¹³ examined the impact of intrathecal baclofen on the natural history of scoliosis in cerebral palsy patients. Intrathecal baclofen has been shown to be an effective treatment for spasticity in patients with cerebral palsy; however, questions have been raised as to whether progression of scoliosis occurs as a side effect of this treatment. The authors examined fifty patients who received intrathecal baclofen as part of the treatment of spasticity and compared them with fifty control patients who did not receive the intervention. Annual progression of scoliosis in these patients was compared with use of Cobb angle measurements. In addition, a multiple linear regression model was used to examine the differences between the two groups while controlling for age, sex, topographic involvement, and the initial Cobb angle.

The results of that study showed that patients who received intrathecal baclofen as a treatment for spasticity had progression of neuromuscular scoliosis that was no different from that in patients who did not undergo the treatment. That study should quell concerns that intrathecal baclofen can lead to progression of scoliosis that may not have otherwise occurred without intervention, allowing patients to continue to receive the benefits from intrathecal baclofen treatment.

Turning from the pharmacologic interventions of botulinum toxin and baclofen to surgical intervention, Gough et al.¹⁴ examined the outcome of surgical intervention for the treatment of early deformity in young patients with bilateral spastic cerebral palsy who were able to walk. The initial management of these young children generally has concentrated on therapy, orthoses, and casting in the hopes of preventing deformity from occurring. Surgical interventions are delayed to allow a more mature gait pattern and to prevent a recurrence of deformity as growth occurs. The authors sought to determine if patients younger than eight years of age who had bilateral spastic cerebral palsy and who underwent surgical intervention could maintain an improvement in gait for at least two years. This improvement would need to be greater than the deterioration that would be shown in children who did not undergo surgical intervention. It was hoped that this would parallel the positive results associated with surgical intervention (and deterioration associated with conservative measures) seen in older patients with cerebral palsy.

The authors examined thirteen patients, seven years of age and younger, with bilateral spastic cerebral palsy who had undergone gait analysis and surgical intervention and compared them with eleven patients with bilateral spastic cerebral palsy who also had undergone gait analysis and for whom surgery was also recommended but was not performed. The gross motor classification system was calculated, as was the mean number of procedures in the surgical treatment group. In addition, the Gillette gait-analysis index, the mean minimum knee flexion in stance, the mean popliteal angle, and the mean maximum passive dorsiflexion (knee extension) were calculated. The authors found that the operative treatment group had improvement in outcome measures, including the Gillette gait index (p = 0.001), minimum knee flexion in stance (p < 0.001), and maximum degree of dorsiflexion (p < 0.0001), through the time of the second postoperative gait analysis. The popliteal angle improved after surgery but returned to the preoperative baseline at the time of the second postoperative gait analysis. In the control group, four children had improvement of >10% in the Gillette gait index, one remained stable, and six showed a deterioration of >10%. The control group also had an increase in minimum knee flexion in stance.

The results of that study support the notion that surgical intervention can be utilized to improve or maintain the mobility of the young patient with bilateral spastic cerebral palsy who is able to walk. It is important to note that the authors did not advocate for routine operative management for this patient population but proposed it is an effective option if traditional nonoperative methods fail.

Whereas the previous study examined operative interventions for pediatric patients with cerebral palsy, Smith et al.¹⁵ examined the use of two different types of braces for patients with diplegic cerebral palsy and a jump gait pattern. Whereas ankle-foot orthoses have been shown to help to facilitate normal gait, we are not aware of any studies that have shown superiority of a hinged ankle-foot orthosis over a dynamic ankle-foot orthosis in highly functional (Gross Motor Function Classification System level-I) patients with cerebral palsy who walk with a jump gait pattern. Fifteen children with spastic diplegic cerebral palsy and twenty children with normal gait were compared. Subjects were tested while barefoot, while wearing the hinged orthosis, and while wearing the dynamic ankle-foot orthosis. The authors found increases in stride length and walking speed and decreases to normal cadence in association with both braces as compared with barefoot walking. Furthermore, when either of the two braces was worn, the cerebral palsy group did not differ from the control group in terms of stride length, walking speed, or cadence. In addition, the two braces equally improved ankle kinematic and kinetic parameters in the cerebral palsy group. Of note, although gait parameters did improve, the results on the Pediatric Outcomes Data Collection Instrument and the Gross Motor Function Measure were not different among the three groups (indicating that there was no detectable change in the patients' perceived functional activities). The authors thought that this finding may have been due to the already high functional level of the patients in the study.

The results of that study suggest that ankle-foot orthoses are indeed effective for the treatment of patients with diplegic cerebral palsy and a jump gait pattern. The specific brace that is utilized (hinged or dynamic) does not seem as important because both were effective for normalizing gait. Additional study is necessary to determine if there are other bracing factors (height of orthoses, cosmesis, cost, etc.) that may lead to variable outcomes in terms of gait and the patient's perception of functional improvement.

Heterotopic Ossification

Heterotopic ossification is the abnormal development of bone in areas of the body other than skeletal tissue. It is commonly known to complicate total hip arthroplasty and has a strong association with traumatic brain injury as well as spinal cord injury¹⁶. Heterotopic ossification also can cause complications in joints other than the hip in patients with or without neurologic injury. Although heterotopic ossification of the shoulder and elbow joints is usually described in patients with traumatic brain injury, recent studies have shown significant rates of heterotopic ossification in patients without neurologic insult who undergo common procedures such as hemiarthroplasty¹⁷ and reverse total shoulder arthroplasty¹⁸.

The role of bone morphogenetic protein (BMP) signaling as an important regulator of ectopic bone formation continues to be the focus of research attempting to elucidate the pathophysiology behind heterotopic ossification. Excessive BMP signaling has been implicated as a major contributor to osteoblastic differentiation of mesenchymal stem cells. Patients with the congenital disorder fibrodysplasia ossificans progressiva have a mutation in the ACVR1 gene that is thought to lead to constitutive activation of BMP type-I receptor activity¹⁹. Activation of this group of receptors upregulates the transcription of genes important in growth and the differentiation of pluripotent mesenchymal stem cells that lead to the formation of ectopic bone. Yu et al.²⁰ recently identified a small molecule that effectively inhibited transcriptional activity of BMP type-I receptors and demonstrated disruption of the osteoblast differentiation signaling pathway. That group also described a transgenic mouse model of heterotopic ossification that mimics the intramuscular endochondral bone formation as well as the radiographic and functional outcomes of human fibrodysplasia ossificans progressiva. Using this mouse model, they demonstrated how an inhibitor of BMP type-I receptors can disrupt ectopic ossification. Kan et al.²¹ similarly described an animal model of heterotopic ossification that implicated dysregulation of local progenitor cells as another cellular mechanism for ectopic bone formation.

Recombinant bone morphogenetic proteins such as rhBMP-2 and rhBMP-7 have a wide range of therapeutic applications, including United States Food and Drug Administration-approved use for the treatment of recalcitrant nonunions as well as for spine fusions. These two recombinant proteins have been shown to induce BMP-4 expression²², which is a crucial component of the heterotopic ossification pathway. However, recent studies have suggested that diffusion of these materials into local soft tissue may lead to ectopic bone formation^23-25. Axelrad et al.²³ described four cases of heterotopic ossification that occurred in patients with acute humeral fractures and humeral nonunions that were treated with rhBMP-2 or rhBMP-7. Symptomatic heterotopic ossification occurred in these patients between six and ten weeks after open reduction and internal fixation. Three of the four patients underwent excision of the ectopic ossification, with improvement in range of motion and pain relief. Wysocki and Cohen²⁴ similarly described a case of ectopic ossification of the triceps after the use of BMP-7 to augment bone healing at the site of a distal humeral fracture. Lumbar fusion surgery utilizing BMP-2 also has been shown to cause extensive bone formation in the psoas and iliacus muscles²⁵. Given the findings of those reports, rhBMP should be used with caution, especially in periarticular areas. We suggest maintaining meticulous hemostasis and avoiding wound irrigation after BMP placement to reduce the formation of ectopic bone in the surrounding area.

In a retrospective review of the medical complications and physical function of 121 patients with traumatic brain injury, Safaz et al.²⁶ found a high rate of heterotopic ossification. The diagnosis was made on the basis of radiographic findings and increased levels of serum alkaline phosphatase in patients with clinical signs such as pain, decreased range of motion, swelling, and erythema. Twenty-one of the 121 patients had development of heterotopic ossification in a total of forty-four joints, including twenty-three hips, nine elbows, seven knees, and five shoulders. With the exception of one patient, all joints with heterotopic ossification were on the plegic side. Patients with heterotopic ossification had decreased walking ability as compared with patients without heterotopic ossification. It is unclear whether heterotopic ossification resulted in physical limitations that restricted walking or whether increased heterotopic ossification and decreased walking ability were each independently associated with injury severity. Mitsionis et al.²⁷, in a recent study of fourteen patients in the intensive care unit who had substantial heterotopic ossification, reported that surgical excision of ectopic bone improved range of motion (in nineteen of twenty-three knees) and sitting ability (in thirteen of the fourteen patients). Improvements in walking ability were seen in eight of the fourteen patients. The authors supported the role of surgical excision for the treatment of heterotopic ossification in the knee in order to improve range of motion, sitting ability, and overall walking ability.

Heterotopic ossification is a frequent complication after total hip arthroplasty, with a reported prevalence of between 15% and 90%. In a study of 103 surface replacement arthroplasties and ninety-seven total hip arthroplasties, Rama et al.²⁸ compared the prevalence and severity of heterotopic ossification associated with these two procedures. A significantly higher rate of severe heterotopic ossification was found in the surface replacement group (12.6% [thirteen of 103] compared with 2.1% [two of ninety-seven]). This difference may be related to the more extensive surgical approach to the femoral head in surface replacement.

Other modalities for decreasing the rate of heterotopic ossification in patients managed with hip replacement involve the choice of pharmacologic thromboprophylaxis after total hip arthroplasty. There is controversy over whether aspirin decreases the prevalence of heterotopic ossification. This theory was investigated by Bek et al.²⁹, who retrospectively compared the prevalence and severity of heterotopic ossification between sixty-seven patients using warfarin and sixty-six patients using aspirin for postoperative thromboprophylaxis after staged bilateral total hip arthroplasty. At the time of follow-up, one year later, heterotopic ossification was seen in 124 hips (46.6%) in seventy-eight patients (59%) according to the Brooker classification system. A significantly lower rate of heterotopic ossification was found for the patients using aspirin for prophylaxis (forty-three hips; 34.7%) as compared with those using warfarin (eighty-one hips; 65.3%). In addition, significantly more patients had Brooker class-III and IV heterotopic ossification in the warfarin group. Of note, in the warfarin group, there was a significantly higher rate of treatment with use of fixation without cement, which previously has been associated with an increased prevalence of heterotopic ossification. However, the authors still concluded that aspirin may be more effective than warfarin for the prevention of heterotopic ossification after total hip arthroplasty.

Various studies comparing radiation therapy with indomethacin for prophylaxis against heterotopic ossification have shown inconclusive results. Blokhuis and Frölke³⁰ performed a systematic review of five studies involving 384 patients that compared indomethacin (224 patients) with radiation therapy (160 patients) for prophylaxis against heterotopic ossification after the fixation of acetabular fractures. As a result of the usual high-energy trauma associated with acetabular fractures, there is an increased frequency of concomitant head injury that has been linked with an increased risk of ectopic ossification. Heterotopic ossification developed in five of 160 patients managed with radiation, compared with twenty of 224 patients managed with indomethacin. The authors concluded that the current evidence supports the use of radiation therapy after acetabular surgery when practical. When radiation is not feasible, indomethacin is considered to be the gold standard for prophylaxis against heterotopic ossification after acetabular surgery, as well as after total hip arthroplasty³¹. For total hip arthroplasty, other nonsteroidal anti-inflammatory drugs such as naproxen and diclofenac have been shown to prevent clinically important heterotopic ossification and can be considered as alternative first-line therapy. Although it should be used with caution because of a possibly increased risk of cardiovascular complications, celecoxib has efficacy equal to indomethacin and is associated with significantly fewer gastrointestinal side effects.

Spinal Cord Injury

Basic science research investigating the role of the immune system after spinal cord injury has the potential to identify therapeutic interventions aimed at improving functional recovery after such an injury. However, reparative or protective immune mediators must be distinguished from components of the inflammatory response that contribute to the substantial secondary damage seen after injury. In addition, their temporal relation to injury also must be clarified in order to allow for the optimal targeting of specific aspects of the immune response that will limit secondary cell death, prevent axonal degeneration, and promote sensorimotor function recovery. Both immunostimulatory and immunosuppressive therapeutics have had promising results.

Infection is the leading cause of death in the post-acute phase of spinal cord injury. Although the high susceptibility to infection following spinal cord injury was previously attributed to iatrogenic methylprednisolone therapy, recent literature has supported the theory that spinal cord injury induces a secondary immune depression syndrome, also termed spinal cord injury-induced immune depression syndrome (SCI-IDS). In both an animal model³² and a human study³³, Riegger et al. monitored immune cell fluctuations after spinal cord injury. In the animal model, populations of innate and adaptive immune cells were monitored in rats undergoing experimentally induced spinal cord injury and were compared with those in control rats undergoing a sham operation. Decreased levels of monocytes, T-lymphocytes, B-lymphocytes, MHC II+ cells, and dendritic cells were seen as early as twenty-four hours after the injury, indicating suppression of the innate and adaptive immune system. Similar results were found in the human study, with decreases in comparable cell lines evident at twenty-four hours after the injury. In another study, Campagnolo et al.³⁴ showed a significant reduction in natural killer cells when patients with a spinal cord injury were compared with normal controls. The level of neurologic injury did not have an impact on the level of reduction in a decentralized as compared with an intact sympathetic nervous system. Additional investigation into the mechanism behind immune depression after spinal cord injury can provide the basis for future therapeutic interventions modulating these immune responses and decreasing the morbidity and mortality related to infection.

Other studies of spinal cord injury have investigated the theory behind an intense inflammatory response causing secondary damage at the site of injury. Leukocytosis is a well-known response to physical trauma, and animal studies have shown that injury to the central nervous system causes a more intense inflammatory response than general trauma does. In a study of nine patients with a spinal cord injury, Bao et al.³⁵ investigated the oxidative activity of human blood neutrophils and monocytes and compared this profile with that for ten uninjured controls as well as six trauma controls who had sustained severe osseous fractures but no central nervous system injury. Blood samples that were obtained six hours to two weeks after the injury were analyzed for oxidative activity with use of various methods. Neutrophil counts were higher in patients with spinal cord injury and controls with a traumatic injury as compared with normal controls. The oxidative burst activity of neutrophils and monocytes was increased fourfold to sixfold in comparison with that in uninjured subjects starting at twelve hours after the injury and continuing for as long as one week, reaching a maximum increase at twenty-four hours. This activity in the patients with spinal cord injury was also significantly greater in comparison with that in the controls with a traumatic injury. The authors suggested that this inflammatory response could be a target for agents and interventions that limit the migration of neutrophils and monocytes into the injured spinal cord and thereby decrease secondary damage. Stammers et al.³⁶ also recently described the temporal expression of inflammatory cytokines in patients with an acute spinal cord injury. Levels of IL-6, IL-10, IP-10, MCP-1, TNF-R1, and tau in cerebrospinal fluid were found to be elevated within twenty-four hours after spinal cord injury and tended to decrease over the next seventy-two hours. As shown by Yaguchi et al.³⁷ in a mouse model, immediate administration of IL-12 into a hemisectioned spinal cord in mice resulted in a significant increase in the number of activated microglia and dendritic cells on immunohistochemical analysis as well as a significant improvement in locomotor function. This finding suggests that regulation of these cellular immune responses may promote functional recovery.

Prediction of the outcome after spinal cord injury plays an important role in planning a rehabilitation program. It also helps in understanding the socioeconomic implications. The National Institute on Disability and Rehabilitation Research (NIDRR) Spinal Cord Injury Measures Meeting Neuroimaging Committee advocated the need for future studies investigating the prognostic ability of magnetic resonance imaging. Furlan et al.³⁸ conducted a multicenter prospective cohort study with use of quantitative and qualitative magnetic resonance imaging parameters to predict long-term neurologic recovery in patients with spinal cord injury. Sixty patients with a traumatic cervical spine injury were followed for an average of 6.7 months. Clinical data, including the American Spinal Injury Association Impairment Scale (AIS) grade, six qualitative magnetic resonance imaging parameters (hemorrhage, edema, disc herniation, canal stenosis, swelling, and soft-tissue injury), and three quantitative magnetic resonance imaging parameters (maximum canal compromise, maximum spinal cord compression, and length of injury within the spinal cord), were recorded. The study population was divided into two groups: one group with similar AIS scores at the times of admission and follow-up and another group with conversion of at least one AIS grade between the times of admission and follow-up. Analysis showed that neurologic improvement was associated with both the absence of hemorrhage and a smaller lesion length, but neither parameter was significant. Additional investigations are needed to define the role of magnetic resonance imaging in predicting clinical outcome.

Functional recovery following a spinal cord injury is thought to arise from multiple mechanisms. These include compensation, whereby functional improvement occurs independently from neurologic recovery, and neuroplasticity, in which reorganization of neuronal circuits leads to functional improvement. Repair mechanisms such as remyelination and regeneration of the damaged spinal tract are not thought to significantly contribute to functional recovery³⁹. Exercise may be beneficial for enhancing neuroplasticity, as suggested by a recent study that showed elevated levels of neuroplasticity-related proteins in paraplegic elite athletes after exercise⁴⁰. A multitude of exercises can be employed for patients with a spinal cord injury, but it is difficult to assess which exercises are best suited to increasing physical capacity and functional activity. Proponents of activity-dependent neuroplasticity support the use of locomotor training such as functional electrical stimulation and weight-supported treadmill training for improving walking ability⁴¹. Many studies have supported upper body and upper extremity training as an effective means of improving overall physical capacity⁴².

More specifically, hand cycling has recently been employed as a mode of exercise in certain rehabilitation centers and even for tetraplegic patients with partially paralyzed arm muscles. This exercise modality is less strenuous than wheelchair propulsion and is less likely to cause upper extremity overuse injuries. Valent et al.⁴³ investigated the effect of hand cycling on physical capacity in 162 patients with a spinal cord injury. The patients were separated into two groups; one group performed hand cycling at least once a week, and the other group did not perform hand cycling. Regression analysis revealed a significant relationship between hand cycling and increases in peak power output, peak oxygen uptake, and elbow extension strength in paraplegic patients during clinical rehabilitation. However, these results were no longer significant when analyzed one year after clinical rehabilitation. The authors suggested that patients in the hand-cycling group reached a higher physical capacity on discharge, and, therefore, post-rehabilitation differences were not as apparent. As expected, lower gains were found in tetraplegic patients, with no significant difference found at any time period, likely because of the heterogeneity of the group. Therefore, that study argues for regular hand-cycling training as an effective method for improving aerobic physical capacity.

Upper extremity training is promising as an effective means of rehabilitation for paraplegic patients⁴² but may not be the optimal intervention for quadriplegic patients with limited upper extremity function. Alternatively, surgical intervention such as upper extremity tendon transfers can play an important role in improving the ability of these patients to participate in activities of daily living. Anderson et al.⁴⁴ conducted a survey of 137 patients with a cervical spinal cord injury to determine how they viewed tendon transfer surgery. Fewer than 50% of the patients had any knowledge of tendon transfer surgery, and tendon transfer surgery had been performed for only 9% of the patients. Nearly 80% of the respondents reported that they would be willing to undergo tendon transfer surgery knowing that they would have decreased independence for two to three months during recovery, with the ultimate goal of being more independent afterward. From the patient's perspective, the optimal timing of surgery would be within five years after the injury. The authors concluded that regaining arm and hand function is vitally important to this group of patients and that awareness of tendon transfer surgery needs to be improved.

The diagnosis of traumatic brain injury in patients with a traumatic spinal cord injury presents a complex clinical challenge. Conventional rehabilitation methods for patients with a spinal cord injury require the ability to acquire new knowledge and skills to relearn and regain function; this ability is often compromised in patients with a traumatic brain injury. As documented by Macciocchi et al.⁴⁵, the diagnosis of concomitant traumatic brain injury is often missed in the acute-care setting, signifying the need to educate hospital staff on the impact of having both diagnoses on the acute rehabilitation needs. Patients who have a spinal cord injury with a concomitant traumatic brain injury achieve smaller functional gains than those without traumatic brain injury⁴⁶, and a recent prospective case-matched control study by Bradbury et al.⁴⁷ showed an association between prolonged loss of consciousness and significantly worse neuropsychological test performance. Furthermore, the authors found the Functional Independence Measure cognitive subscale, a common screening test of cognitive status used for inpatient spinal cord rehabilitation programs, to be an inadequate measure of cognitive impairment. Not surprisingly, concomitant traumatic brain injury was also associated with increased daily rehabilitation costs and greater demands on clinician resources and specialized services.

Life satisfaction after spinal cord injury was recently quantified in two studies. Van Koppenhagen et al.⁴⁸ analyzed determinants of life satisfaction in adult patients with a spinal cord injury. At the commencement of active rehabilitation, 147 patients were asked to retrospectively report life satisfaction before the injury. One year after discharge, participants were asked to rate their current life satisfaction. The correlation of the results with demographic and lesion characteristics was analyzed, and moderate decreases in life satisfaction were found between the two time points. Decreases in self-care, vocational situation, and sexual life were most significant. Partner relations, family life, and contacts with friends and acquaintances appeared to be least affected and were found to be higher in some participants. High lesion level, pain, and secondary impairments were also found to be significant determinants of life satisfaction. Chen et al.⁴⁹ performed a similar but longer-term prospective cohort study evaluating life satisfaction over a decade for adult patients with pediatric-onset spinal cord injury. The authors examined life satisfaction for 278 patients with an average age of 27.1 years; the average time since the injury was 12.8 years. Satisfaction With Life Scale scores increased gradually over time. Injury severity did not have an effect on satisfaction, but a lower level of injury (T7 to S5 as compared with C1 to T6) was associated with a significantly greater increase in life satisfaction over time. Patients who were employed or who were students and those who were married or living with a partner had better life satisfaction, stressing the importance of spouse and peer support in rehabilitation. Illicit drug use had a significantly negative association. The authors found several modifiable risk factors that, if targeted for intervention, could minimize the risk of diminishing life satisfaction.

Patients with a spinal cord injury often require long hospital stays in specialized spinal cord injury units, resulting in a high personal and economic burden of care. Because patients with spinal cord injury often live in areas where medical and nursing staff with spinal cord injury expertise is unavailable, telemedicine is emerging as an effective method of improving the quality of care after discharge.

Although telemedicine is conceptually effective, the number of valid studies quantifying improved functional outcomes and decreased clinical complications is scarce. Dallolio et al.⁵⁰ conducted a multicenter randomized controlled trial of 127 patients with a spinal cord injury to evaluate the six-month outcomes of telemedicine as compared with those of standard care. Telerehabilitation was performed at three different sites in Belgium and Italy with use of dedicated video-conferencing consisting of weekly sessions for the first two months, followed by biweekly sessions for four months. Baseline functional measurements that were obtained ten days before hospital discharge were compared with functional outcomes at two and six months after discharge. There were no significant differences between the two groups with regard to the number or type of clinical complications or the number of hospital readmissions. One of the three sites showed significantly higher gains in the telemedicine group, with improved grooming, dressing the upper and lower body, and bed/chair/wheelchair transfers contributing the most to this difference. The telemedicine group reported significantly higher satisfaction with care. Along with telerehabilitation, Goodman et al.⁵¹ suggested that computer and Internet use by patients with a spinal cord injury holds considerable potential as a long-term treatment modality. Additional studies are required to quantify whether telemedicine can potentially be cost saving.

Diabetes and Involvement of the Lower Extremity

Diabetes-related complications involving the lower extremity are associated with a high rate of morbidity and mortality and impose a tremendous burden on the health-care system, and the paucity of well-designed randomized clinical trials makes it difficult for physicians to make sound evidence-based decisions. Hence, the outcomes of treatment are often poor. It is well accepted that a multidisciplinary approach to the diabetic foot is necessary for favorable results. In an effort to standardize diagnosis and management, the International Working Group on the Diabetic Foot has produced a series of systematic reviews and guidelines^52-54.

Compared with healthy individuals, diabetic patients have a tenfold increased risk for soft-tissue and bone infections of the lower extremity, with the health of as many as 20% of diabetic individuals being complicated by osteomyelitis. However, making the definitive diagnosis of osteomyelitis in the diabetic foot is difficult because there is no highly sensitive and specific diagnostic test available. This is further complicated by the late onset of radiographic features of osteomyelitis on plain radiographs and the high rate of peripheral neuropathy, which masks the usual symptoms of infection. Two systematic reviews analyzed the accuracy of clinical examination and imaging tests in the diagnosis of osteomyelitis in this population. In the methodologically rigorous study by Dinh et al.⁵⁵, a total of nine articles met the inclusion criteria for the analysis. The "probe-to-bone" test (the ability to probe a wound for bone without any intervening soft tissue) had a sensitivity of 0.60 and a specificity of 0.91. Of the imaging modalities, magnetic resonance imaging was more useful (sensitivity, 0.90; specificity, 0.79) than leukocyte scans and relatively nonspecific bone scans. Butalia et al.⁵⁶, in a review of twenty-one studies, reported similar findings: the "probe-to-bone" test and an ulcer area of >2 cm² were the most reliable clinical examination findings, and magnetic resonance imaging had the highest overall accuracy of the imaging modalities, with a weighted sensitivity and specificity of 89%. However, magnetic resonance imaging findings must be interpreted cautiously as previous studies attempting to correlate magnetic resonance imaging findings with histologic findings have shown that marrow edema can be difficult to distinguish from osteomyelitis. The detection of osteomyelitis in tarsal bones in particular has a particularly low specificity⁵⁷. The investigators concluded that there is no examination or imaging feature that reliably excludes osteomyelitis in the diabetic foot.

Diabetic patients with osteomyelitis of the foot have a high likelihood of requiring a lower extremity amputation. Therefore, prompt and effective treatment is necessary. Unfortunately, there is currently no consensus for the standard for treatment. Berendt et al.⁵³ conducted a systematic review of 1168 studies, but only nineteen met the inclusion criteria. There was little evidence to encourage surgical intervention over medical management. In addition, the results regarding the choice and duration of antibiotics as well as those regarding the effectiveness of other adjunctive therapies such as revascularization and hyperbaric oxygen therapy were inconclusive. The authors concluded that the quality of published work in the area is poor, with few controlled randomized studies, and that there are no data to support the superiority of one intervention over another at this time.

The treatment of infected wounds in the diabetic foot usually consists of oral or parenteral antibiotics with polymicrobial coverage. Lipsky et al.⁵⁸ conducted two consecutive double-blind, randomized, controlled, multicenter trials in which topical antimicrobial therapy was compared with oral antibiotic therapy for the treatment of mild diabetic foot infections. A total of 835 patients with infected full-thickness wounds were randomized to either the local application of 2% pexiganan acetate cream twice daily or treatment with oral ofloxacin twice daily for two to four weeks. Patients in the pexiganan treatment group received placebo tablets, whereas those in the ofloxacin treatment group received placebo cream. There was a lower percentage of clinical improvement in the topical treatment group at both four and six weeks, although the difference was not significant. Bacterial resistance emerged in some patients taking ofloxacin but not those using the topical cream. The authors concluded that topical pexiganan is a therapeutic alternative to broad-spectrum oral antibiotics for the treatment of mildly infected diabetic foot ulcers, with the possible benefit of reducing bacterial resistance seen in association with oral antibiotic administration. In contrast, Hinchliffe et al.⁵⁴, in a systematic review of interventions for enhancing the healing of chronic diabetic foot ulcers, did not find any data to support the use of any topically applied product or dressing. Their study supported the use of systemic hyperbaric oxygen therapy and topical negative-pressure therapy.

Footwear and off-loading techniques are commonly used for the prevention and treatment of diabetic plantar foot ulcers. These interventions include four main groups: casting techniques such as total contact casts; footwear such as socks, insoles, and orthoses; surgical off-loading techniques such as Achilles tendon lengthening, arthroplasty, and osteotomy; and other off-loading techniques such as crutches, walkers, and bracing. Bus et al.⁵² systematically reviewed twenty-one Level-I and II studies as well as 108 Level-III studies to determine whether the current literature supports the use of these therapeutic interventions for the prevention and treatment of diabetic foot ulcers. Surgical off-loading techniques such as Achilles tendon lengthening, surgical excision of osseous prominences, joint arthroplasty, and metatarsal head resection appear to provide a reduced risk of ulcer recurrence when compared with nonsurgical measures. Studies with appropriate methodology evaluating footwear and off-loading devices for the prevention of ulcer recurrence were lacking. While total contact casting has been accepted as an effective treatment for diabetic foot ulcers and evidence shows that it leads to healing of a higher proportion of plantar ulcers at a faster rate than other off-loading modalities⁵⁹, a recent study involving 901 geographically diverse centers across the United States showed that shoe modifications were used in favor of total contact casting for the treatment of ulcers, with total contact casting being used at only 1.7% of the centers⁶⁰.

The rate of complications for diabetic patients managed both operatively and nonoperatively for ankle fractures is higher than that for nondiabetic patients. Wukich and Kline⁶¹ reviewed the specific characteristics that must be considered when treating ankle fractures in this patient population. Comorbidities such as vasculopathy, neuropathy, and Charcot arthropathy must be taken into consideration as the risk of complications is higher in diabetic patients with comorbidities than in those without. Stable, nondisplaced fractures can be successfully treated with nonoperative measures, whereas unstable fractures should be treated with surgical intervention. Although there is a trend toward the use of supplemental fixation for patients with neuropathy, there are insufficient data to make this recommendation. Studies do support a prolonged period of non-weight-bearing for both nonoperative and operative interventions. Optimization of treatment will require additional studies in this area.

Chronic Wounds

Chronic wounds are defined as wounds that do not have anatomic and functional integrity after three months⁶². The Wound Healing Society uses the TIME acronym to define the important elements of wound-healing. "T" refers to the removal of nonviable or unhealthy tissue, "I" refers to the presence of inflammation and the control of infection, "M" stresses the importance of moisture balance, and "E" refers to the advancing wound edge and re-epithelialization. To address these four components, there are numerous treatment modalities, including wound débridement, pressure off-loading, addressing vascular deficiency, and treatment of infection. Although these modalities are considered by many to be accepted standards for wound care, the benefits and effectiveness of these therapies are based mainly on experience, without randomized controlled trials to definitively support their use. In recent years, advanced therapies to augment these basic cornerstones of wound therapy have been investigated. These therapies include, among others, specialized dressings, noncontact ultrasound, and negative-pressure wound therapy. Both the large number of treatment modalities available and the various indications for each of these interventions make the use of evidence supporting one treatment over another especially challenging. In addition, many of the novel treatments are often expensive, adding to the already enormous cost of wound-care therapy.

The development of pressure wounds is a frequent complication in patients who have a spinal cord injury and is one of the most frequent causes of hospital readmission. A recent study by Smith et al.⁶³ highlighted the risk factors for the development of pressure ulcers in veterans with a spinal cord injury. A total of 2574 patients responded to the Spinal Cord Dysfunction Health Care Questionnaire that was mailed to them. The primary outcome measure was the presence or absence of one or more pressure ulcers during the past year. Thirty-six percent of respondents had one or more pressure ulcers, with an average of 2.63 ulcers within that group. Analysis of demographic characteristics revealed a significantly lower prevalence of pressure ulcers in veterans who were married or employed. Patient age was not a predictor of ulcer formation, but patients who had sustained the injury more than twenty years ago were more likely to have development of pressure wounds. Interestingly, only 34.2% of veterans with service-connected injuries had development of pressure ulcers, compared with 44.9% of those with non-service-connected injuries. Also, veterans who reported receiving all of their health care in the Veterans Administration system were less likely to report any pressure ulcers in comparison with veterans who received their care in a non-Veterans Administration setting. Medical comorbidities that were associated with an increased prevalence of pressure ulcers included diabetes, hypertension, and depression. Thus, the authors concluded that the use of more aggressive prevention strategies should focus on individuals with a high burden of chronic illnesses such as diabetes or depression. Furthermore, the prevalence of pressure ulcers was also higher in current smokers, emphasizing the importance of smoking cessation as a crucial part of ulcer prevention.

The importance of patient education and a structured follow-up program for chronic ulcers in military veterans was also shown by Rintala et al.⁶⁴. In a randomized controlled trial evaluating the effectiveness of a two-year structured follow-up program after surgical repair of stage-III or IV pressure ulcers in veterans with spinal cord injury, forty-one patients were divided into three groups: Group 1 comprised twenty patients who received enhanced education and monthly follow-up evaluations for as long as two years after discharge, Group 2 included eleven patients who received monthly contacts for as long as two years but no enhanced education during or after hospitalization, and Group 3 included ten patients who received minimal contact every three months for as long as two years. Enhanced education consisted of four one-hour one-on-one sessions with an occupational therapist with expertise in the prevention and treatment of pressure ulcers, and at least one session was done with a family member or significant other. Patients in Group 1, who received enhanced education, had a reduced rate of recurrence as compared with patients in Groups 2 and 3 (33%, 60%, and 90%, respectively) and were ulcer-free for a significantly longer time period as compared with patients in Groups 2 and 3 (19.6, 10.1, and 10.3 months, respectively). Health status and the level of the spinal cord injury were not predictive of ulcer recurrence or ulcer-free survival time. Although there was insufficient power to confirm the hypothesis, the study suggested that individualized one-on-one education and structured follow-up effectively reduce ulcer recurrence in this population.

Chronic wounds are prevalent in residents of long-term-care facilities, and the outcomes for these patients are poor. Takahashi et al. described the factors affecting chronic wound-healing⁶⁵ as well as the long-term outcomes for these patients⁶⁶. In a retrospective cohort study of 397 long-term-care residents, the investigators found that 66% of the ulcers did not heal. Residents with diabetes mellitus, peripheral vascular disease, a greater number of wounds, and a larger wound area had a significantly greater odds ratio for wound nonhealing; after multivariate analysis, only the number of wounds and the hemoglobin level were significant predictors for nonhealing. In another study, involving 411 long-term-care residents, Takahashi et al. found that the number of chronic wounds had a significant association with six-month mortality after adjustment for other comorbid health conditions, with an odds ratio of 1.32. The authors suggested that health-care providers should set realistic expectations for patients with multiple chronic nonhealing ulcers because their presence indicates decreased overall patient health and portends a higher mortality rate.

Recent evidence supporting the use of noncontact ultrasound for the treatment of chronic wounds has been accumulating. In a prospective randomized study of seventy patients with critical limb ischemia (defined as a transcutaneous oximetry value of <40 mm Hg), Kavros et al.⁶⁷ examined the impact of this therapy as an adjunct to conventional therapy. At twelve weeks, a significantly higher percentage of patients had >50% reduction in wound size when managed with noncontact low-frequency ultrasound three times per week as compared with those who received standard wound care (63% compared with 29%). A similar retrospective review by Kavros et al.⁶⁸ also showed a faster rate of healing in the group managed with ultrasound. Moreover, Bell and Cavorsi⁶⁹ performed a retrospective review of seventy-six patients who received conventional outpatient wound care with noncontact ultrasound therapy for the treatment of nonhealing wounds and found a median wound area reduction of 79%. Serena et al.⁷⁰ also showed that noncontact ultrasound reduced the bacterial quantity in chronic wounds. Those studies all contributed more data supporting the use of this relatively new form of wound therapy.

One of the more popular types of specialized dressings for the treatment of chronically infected wounds are silver-coated dressings, which are currently approved by the United States Food and Drug Administration for the treatment of full and partial-thickness wounds, partial-thickness burns, skin grafts, donor sites, and dermal ulcers. Moore et al.⁷¹ reported their experience with a silver-coated polymeric substrate-containing dressing in ninety-seven patients with diabetic, ischemic, venous, or traumatic wounds. At a median of seventy-four days, thirty-five (36.1%) of the ninety-seven wounds had completely healed. The median decrease in wound size was 55.2% at 86.5 days. Of the multiple comorbidities that were analyzed in the study, only hypertension was associated with a lower percentage of healing. Lo et al.⁷² also systematically reviewed the use of silver-releasing dressings in the treatment of infected chronic wounds. Although there was a lack of well-designed studies with standardized outcomes measurements, all of the studies that were included showed positive effects of silver dressings.

Another approach to wound therapy that has gained popularity recently is topical negative-pressure therapy, also known as vacuum-assisted closure. This therapy has received increased attention for the treatment of traumatic wounds and war wounds⁷³. Webb and Pape⁷⁴ discussed the two competing theories behind the mechanism of action of this therapy. The first mechanism involves tissue strain causing the release of growth factors that stimulates tissue regeneration and angiogenesis. The second mechanism involves the removal of excess edematous fluid in the interstitium to allow for improved microcirculation. A cycle in the typical wound involves the release of inflammatory mediators from damaged tissue, capillary leakage, and increased pressure in the interstitial space. This pressure leads to cell death resulting from diminished metabolic exchange. The use of negative pressure to decrease the excess fluid and pressure in the interstitium alleviates capillary afterload, decreases secondary necrosis, and thus decreases the risk of consequent infections. Dedmond et al.⁷⁵ reported on the use of negative-pressure wound therapy for the treatment of soft-tissue injuries in a study of fifty patients with grade-III open tibial shaft fractures. The overall infection rate with use of negative-pressure wound therapy was 30%, with 22% of the patients requiring repeat surgery because of infection. Higher rates were found in patients with grade-IIIB and IIIC fractures. Five of the fifty patients required amputation, and 48% required surgery to facilitate fracture-healing. Free tissue transfer or rotational muscle flaps were required in seventeen patients. The authors compared these results with historical data and concluded that use of negative-pressure wound therapy does not increase the rate of infection and may decrease the need for free tissue transfer or rotational muscle flaps.

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Topics

gait ; amputation ; electromyography ; cerebral palsy ; heterotopic ossification ; pain ; spinal cord injuries ; wounds and injuries ; rehabilitation

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Harish Hosalkar, Nirav K. Pandya, Jason Hsu, Mary Ann Keenan; What's New in Orthopaedic Rehabilitation. The Journal of Bone & Joint Surgery. 2009 Sep;91(9):2296-2310.

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