Extract
Orthopaedic rehabilitation is a unique subspecialty of orthopaedic surgery
that focuses on improving the functional outcome for individuals with
musculoskeletal disability with use of surgical and nonsurgical management.
Orthopaedic rehabilitation focuses on the musculoskeletal system as a whole as
well as on the linkages and couplings between bones, joints, muscles, and the
nervous system. This subspecialty 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 the variety of neurologic disorders
that defy easy classification.
Orthopaedic rehabilitation is a unique subspecialty of orthopaedic surgery
that focuses on improving the functional outcome for individuals with
musculoskeletal disability with use of surgical and nonsurgical management.
Orthopaedic rehabilitation focuses on the musculoskeletal system as a whole as
well as on the linkages and couplings between bones, joints, muscles, and the
nervous system. This subspecialty 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 the variety of neurologic disorders
that defy easy classification.
The current report highlights presentations and advances in several areas
of orthopaedic rehabilitation that were discussed at meetings of the
Orthopaedic Rehabilitation Association, the American Academy of Orthopaedic
Surgeons, and other subspecialty organizations over the past year. The review
also highlights the papers that received the Jacqueline Perry Award and the
Vernon Nickel Award, the two prestigious awards in orthopaedic rehabilitation
that are presented annually by the Orthopaedic Rehabilitation Association.
Gait analysis is an important tool that is used to understand the
complexities of movement and lower extremity function. Such a detailed
description of function has been valuable for determining both nonoperative
and operative management guidelines for individuals with abnormal gait
patterns1. In a
study of patients with spastic paresis of the lower extremity, Kerrigan and
Glenn showed that reduced knee flexion was secondary to dynamic ankle plantar
flexor weakness rather than spastic quadriceps activity, as previously
thought2.
Dynamic polyelectromyography has a proven role in the clinical assessment
of gait and the subsequent planning for the surgical treatment of both upper
and lower extremity neuromuscular disorders. Its use is not limited to
research questions alone. Keenan, Romanelli, and Lunsford performed a dynamic
polyelectromyographic analysis of grasp and release in forty-two patients with
a brain injury associated with spasticity of the hand and
wrist3. They noted
that fourteen muscles had out-of-phase activity that could not be detected on
the basis of a clinical examination alone. Keenan, Haider, and Stone utilized
dynamic polyelectromyography to direct the surgical planning for forty-five
elbows in adults with a traumatic brain
injury4. They noted
that dynamic polyelectromyography revealed a similar pattern of muscular
activity in their patients, especially in the brachioradialis and biceps
muscles. They concluded that elbow flexor spasticity in these two muscles
hindered correct hand placement and found that subsequent selective
lengthening of these muscles improved control and movement. Keenan and Mehta
used dynamic polyelectromyography to help guide their surgical decision-making
in the treatment of shoulder dysfunction in patients with both neurogenic and
mechanical shoulder
problems5. Dynamic
polyelectromyography assisted the physicians in determining the extent of
voluntary muscle control and the general pattern of muscular behavior. Etnyre
et al. concluded that preoperative gait analysis helped surgeons plan for the
surgical correction of equinus gait in children with spastic cerebral
palsy6. Fuller et
al. highlighted the importance of preoperative dynamic polyelectromyography in
the treatment of spastic equinovarus deformity of the foot and
ankle7. When dynamic
polyelectromyographic data were used to assist in operative decision-making,
well over half the initial plans for surgical intervention were modified.
Therefore, it is reasonable to conclude that dynamic polyelectromyography
provides an invaluable tool for surgical decision-making in the treatment of
upper and lower extremity neuromuscular disorders.
It has been common orthopaedic teaching that a more distal amputation level
generally results in better function. Although this concept is intuitive,
scientific studies have helped surgeons to understand that "when
preservation of function is the chief concern, amputation should be performed
at the lowest possible
level"8.
However, recent studies have reevaluated this common orthopaedic philosophy,
especially in patients who have sustained lower extremity amputations. These
studies focused primarily on the patient's perceived level of function, limb
comfort, and other social factors rather than on traditional, clinically
measurable parameters such as walking speed and distance.
In a prospective study of 161 patients who had undergone lower extremity
amputation following trauma, MacKenzie et al. found that although patients
with a below-the-knee amputation had a faster walking speed than those with an
above-the-knee amputation, self-reported functional outcomes were similar
between the two groups after two years of
follow-up9.
Matsen et al., in a study of 148 patients, reported that general
satisfaction, quality of life, freedom from frustration, and walking distance
were strongly correlated with comfort of the residual limb, the condition of
the contralateral limb, the function and appearance of the prosthesis, and the
ability to exercise
recreationally10.
The authors noted that "It was of great interest that the four result
measures were not strongly correlated with the level of amputation." In
an analysis of how successfully young adults are rehabilitated after
below-the-knee amputation, it was shown that 84% of twenty-five patients
regarded themselves as "only slightly or not at all
disabled"11.
Continued advances in rehabilitation medicine have helped amputees to cope
with their loss and to return to a reasonable level of function. According to
Esquenazi and DiGiacomo, exercise techniques, a specific training program, and
environmental modifications all play an important role in rehabilitation after
amputation
surgery12. The
authors detailed an exercise program with four main components (flexibility,
strength, cardiovascular training, and balance and gait), which they credited
with helping to reintegrate amputees into the workforce and community.
Taken together, these studies suggest that understanding the issues facing
amputees, such as those related to activities of daily living and social
factors, may play a more important role than the level of the amputation in
determining function.
Heterotopic ossification, defined as the formation of normal bone in
abnormal locations, is a process that is associated with both common
orthopaedic conditions such as total hip arthroplasty and uncommon genetic
conditions such as fibrodysplasia ossificans progressiva. Unfortunately, as is
the case with the formation of normal bone in the axial and appendicular
skeleton, little is known about the underlying cellular and molecular
mechanisms involved in heterotopic ossification.
The link between brain and bone is evident in many disease processes that
result in heterotopic ossification. The prevalence of clinically important
heterotopic ossification is between 10% and 20% in patients with central
nervous system injuries. Approximately 10% of patients with a traumatic brain
or spinal cord injury experience severe restriction in joint motion or
ankylosis as a result of heterotopic
ossification13. In
one study, heterotopic ossification of the elbow joint developed in >90% of
patients who had sustained a traumatic brain injury along with a
fracture-dislocation of the
elbow14.
Unfortunately, because of the level of unresponsiveness in patients with
central nervous system injuries, fractures may go undetected in these
patients. Garland and Bailey reported undiagnosed fractures in 11% of adult
patients with head
injuries15. The
rate of undiagnosed fractures is reportedly greater in children and was found
to be as high as 40% in one
study16.
Some physicians have recommended guidelines to help decrease the rate of
missed fractures during the early management of multiply injured patients.
Kushwaha and Garland recommended screening plain radiographs of the cervical
spine, thoracolumbar spine, and pelvis for all patients with central nervous
system injuries17.
They also advised that radiographs of the knee should be made for patients who
have been involved in a pedestrian-automobile accident, that a whole-body bone
scan should be performed for skeletally immature patients, and that
electromyographic and nerve-conduction studies should be performed for
patients who are suspected of having clinical signs of neuropathy.
At a molecular level, the formation of heterotopic bone requires three
biological components: an inducible signaling pathway, osteoprogenitor cells,
and an environment conducive to
osteogenesis18.
Although much information has been gained regarding the signaling pathways
required for normal bone formation in developmental processes, little is known
about the formation of bone in the adult model. With the exception of
fracture-healing in animal
models19,20,
normal bone formation remains a perplexing process.
As early as 1965, Urist and many others began the search for processes
responsible for the formation of
bone21,22.
After decades of research, recent advances in molecular biology have helped to
elucidate the molecules and signaling pathways involved in bone formation.
Besides the strong and proven role of bone morphogenic proteins (BMPs) in
inducing bone formation, the overexpression of osteocalcin, type-1 collagen,
and osteonectin23
all have been implicated in the formation of heterotopic as well as normal
bone.
Perhaps the most clinically relevant search for the molecules responsible
for bone induction and formation can be found in the spine fusion
model24,25.
Because of the importance of establishing a solid fusion mass as well as the
morbidity associated with the harvesting of autogenous bone graft, alternative
substitutes—both biological and synthetic—have been advocated for
their osteoinductive as well as their osteoconductive properties. Although
studies of
rabbits26,
dogs27, and
nonhuman primates28
have established the efficacy of BMPs in augmenting spinal fusion, human
studies in the United States largely have been limited to nonunion models.
Fortunately, there is abundant information on the prevention of heterotopic
ossification29,30,
especially in the setting of total hip
arthroplasty31,32.
The sheer volume of total hip arthroplasties performed in the United States
and worldwide makes this an important issue to consider, despite the
reportedly low prevalence of this complication (1%).
Each day, 6000 Americans reach the age of sixty-five years. From 1950 to
2000, the elderly population (that is, individuals who are sixty-five years of
age and older) grew twice as rapidly as the total resident population of the
United States33.
There are currently 35 million people in the United States who are sixty-five
years of age or
older34.
Musculoskeletal diseases and symptoms are the second leading reason why
seniors visit their physicians or are admitted to hospitals.
Osteoarthritis is very common, affecting more than 40 million
Americans35. The
prevalence of osteoarthritis increases with age, and an estimated 70% of
Americans over the age of sixty years are
affected36. Primary
and secondary osteoarthritis have distinct differences, but the overall
picture remains the same. Risk factors such as smoking, obesity, gender,
ethnic background, and genetic predisposition all play roles in diagnostic and
treatment protocols.
Osteoporosis is a complex issue with multiple manifestations. Age-related
changes in bone and soft tissue frequently are associated with disabling
fractures. The diagnosis of osteoporosis is based on a measurement of bone
mineral density37.
Osteoporosis affects approximately 20 million Americans, and 1.2 million
fractures are attributed to this condition each
year38. It has been
estimated that one-half of all women over the age of fifty years and one-third
of all men over the age of seventy-five years will sustain an
osteoporosis-related
fracture39.
Approximately two-thirds of patients who sustain a fracture of the hip do not
return to their prefracture level of
function40,41.
Hip fractures are considered to be the most debilitating fractures in the
elderly
population42,43.
Currently, 250,000 to 300,000 hip fractures occur annually in the United
States44, with the
mortality rate ranging from 14% to 50% within the first year after the
injury45,46.
While the incidence of high-velocity trauma (for example, injuries resulting
from motor-vehicle accidents) has been on the rise in the elderly population,
most of these fractures are still the result of low-velocity injuries, usually
secondary to a
fall47.
The mortality rate associated with peritrochanteric fractures is comparable
with that associated with femoral neck
fractures46.
Currently, the use of extramedullary as opposed to intramedullary devices is
being debated. Extramedullary implant options include a sliding hip-screw with
a side-plate48 and
fixed-angle
devices49. The
screw and side-plate currently is the standard of care for most stable
intertrochanteric hip
fractures50.
Intramedullary devices utilize the familiar concept of the sliding
hip-screw but couple it with an intramedullary rod rather than a femoral
buttress plate. Intramedullary devices are subject to smaller joint-reactive
forces because they are placed more medially in the femoral canal and
therefore are subjected to more favorable biomechanical conditions. These
implants recently have become more popular, with good results having been
reported following the treatment of the challenging reverse obliquity fracture
as well as unstable intertrochanteric
fractures50. The
appeal of a minimally invasive technique and full early weight-bearing are
attractive incentives for their
use51.
Complications usually are secondary to malreduction in varus alignment and
posterior sag. As with extramedullary devices, fracture stability is the key
to proper surgical fixation with use of an intramedullary implant.
Investigators at some centers have been comparing the benefits of primary
total hip arthroplasty with those of unipolar or bipolar arthroplasty for the
treatment of displaced femoral neck fractures in elderly patients. Currently,
unipolar or bipolar hemiarthroplasty is the standard of care for patients
without evidence of acetabular degenerative disease.
Many distal femoral fractures can be treated with intramedullary devices,
with the proximal interlocking screws being used to capture the fracture
fragments. Intra-articular fractures usually are best treated with plates and
screws. Newer implants, such as locking plates, are attractive and offer
biomechanical advantages over traditional plates and screws, but they are
still new devices without an established clinical track record. Early results,
however, have been
promising52.
Outcomes of Surgical Treatment of the Spastic Shoulder
Surgical treatment of shoulder contractures following upper motor neuron
dysfunction has been limited to complete operative release of the muscles,
tendons, and capsule about the shoulder joint or denervation by means of
neurectomy. This rudimentary approach to shoulder contractures does not
differentiate between active and passive contractures about the glenohumeral
joint. Mehta et al. found that approximately 4% of patients with upper motor
neuron disease experience considerable limitation of shoulder function. In
their study of 742 patients with upper motor neuron problems, they found that
twenty-five patients qualified for surgical treatment. They divided their
patients into two groups: those with active dysfunction and those with passive
dysfunction. For patients with active dysfunction, dynamic electromyography
and clinical evaluation were used to help determine the selective surgical
lengthenings necessary to improve the overall range of motion of the shoulder.
For patients with passive dysfunction, a complete contracture release was
necessary, including releases of the pectoralis major, latissimus dorsi, and
teres major muscles. The authors concluded that while the traditional tendon
releases were a reasonable treatment option for patients with static
deformities, more selective surgical lengthenings, based on dynamic
electromyography and clinical evaluation, were warranted for patients with
active shoulder contractures due to upper motor neuron dysfunction.
The Role of Patient Restrictions in Early Dislocation Following
Total Hip Arthroplasty In a prospective, randomized clinical trial
designed to evaluate the role of patient restrictions, Peak et al. found that
removal of traditional restrictions did not increase the incidence of early
dislocation following total hip arthroplasty performed through an
anterolateral approach. However, the authors noted a greater rate of patient
satisfaction as a result of a faster return to function.
Traditionally, surgeons have recommended the use of standard precautions,
including the use of abduction pillows, elevated toilet seats, hip chairs, and
activity restrictions to help decrease the incidence of early dislocation
following a total hip arthroplasty. While these precautions have been thought
to decrease the rate of dislocation following total hip arthroplasty through a
posterolateral approach, no data have suggested that they also decrease the
rate of early dislocation following the use of an anterolateral approach. This
study suggested that the traditional hip restrictions used for the
posterolateral approach to the hip have no significant impact on the rate of
early dislocation in patients managed with total hip arthroplasty through an
anterolateral approach. Similar findings also were reported in a
nonrandomized, prospective clinical
study53.
Orthopaedic rehabilitation covers a wide range of topics involving almost
every segment of the orthopaedic surgical population. From initial evaluation
to postoperative care, an understanding of the most useful diagnostic tests as
well as surgical and nonsurgical orthopaedic rehabilitation options will
greatly facilitate clinical decision-making and treatment.
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