Extract
Orthopaedic rehabilitation involves the care of patients who have complex musculoskeletal problems, which are global in nature. 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.
Orthopaedic rehabilitation involves the care of patients who have complex musculoskeletal problems, which are global in nature. 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.
This specialty update highlights presentations and advances in several areas of orthopaedic rehabilitation discussed at meetings of the Orthopaedic Rehabilitation Association, the American Academy of Orthopaedic Surgeons, and other specialty organizations over the past year. Some abstracts of notable studies in this area of expertise are also succinctly summarized.
Pediatric rehabilitation deals with young patients who have diverse conditions, including neuromuscular diseases, traumatic and congenital disorders leading to amputation, and acute and chronic injuries resulting from high-level athletic demands. Careful physical examination is critical in the analysis of patients who have cerebral palsy. Lee et al.1 examined the validity and reliability of three physical examination tests that are commonly used to measure hip flexion contracture in patients with cerebral palsy who are able to walk. The Thomas test, the prone hip extension test (Staheli test), and the hamstring shift test were examined prospectively in a study of thirty-six patients with cerebral palsy (Gross Motor Function Classification System [GMFCS] level I to III) and thirty-seven children without cerebral palsy. Gait analysis was also performed to determine how the statically measured physical examination values correlated with hip flexion during gait. The authors found that that the Thomas test had the highest intraclass correlation coefficient, the smallest mean absolute difference between measurements, and the most validity in the control group. However, the Staheli test was found to be the most valid in the cerebral palsy group. The hamstring shift test performed the worst of all three tests in terms of intraclass correlation and convergence validity. The authors concluded that the Staheli test was the most valid method for detecting hip flexion contractures in patients with cerebral palsy even though a limitation of this test is that it cannot be used for intraoperative assessment.
The treatment (particularly nonsurgical treatment) of spasticity in patients with cerebral palsy has continued to evolve. Kim et al.2 performed the first study comparing Neuronox with BOTOX for the treatment of equinus gait in children with spastic cerebral palsy. One hundred and one patients with cerebral palsy and spastic equinus gait (GMFCS I to III) (age range, two to ten years) were randomly assigned to receive an injection of Neuronox or BOTOX in the calf muscles at a dose of 4 U/kg for hemiplegic patients and 6 U/kg for diplegic patients. Patients were evaluated at baseline and at four, twelve, and twenty-four weeks after intervention. The outcome measures were the change in the Physicians’ Rating Scale (PRS) score, passive range of motion of the ankle, and Gross Motor Function Measure 88 (GMFM-88). The authors found significant improvements in the PRS score, passive range of ankle dorsiflexion, and the GMFM-88 score in both groups at four, twelve, and twenty-four weeks after intervention. There were no significant differences between the Neuronox and BOTOX groups in terms of the PRS score or passive range of motion of the ankle. The increase in the GMFM-88 score was not significantly different between the two groups at twelve weeks after intervention, although it was higher in the BOTOX group at four and twenty-four weeks after intervention. The authors of this study, one of the first studies comparing the multiple formulations of BoNT-A (Botulinum toxin A), concluded that Neuronox is as reliable and safe as BOTOX for the treatment of spasticity in patients with cerebral palsy.
Whereas the previous study examined the use of BoNT-A for the treatment of patients with lower extremity spasticity, Hoare et al.3 performed an update of the 2004 Cochrane Database Systematic Review examining the use of BoNT-A for the treatment of upper limb spasticity in patients with cerebral palsy. Specifically, the authors assessed the effectiveness of injections of BoNT-A as compared with BoNT-A and occupational therapy. In the included studies, the BoNT-A concentration ranged from 50 to 200 U/1 mL, with doses of 0.5 to 16 U/kg (total doses, 220 to 410 units). The authors found that the BoNT-A with occupational therapy was more effective than occupational therapy alone for reducing impairment and improving activity level in patients with cerebral palsy, but not for improving quality of life or perceived self-competence. Furthermore, when used alone, BoNT-A (supported by moderate evidence) was not effective for spasticity treatment when compared with placebo or no treatment. The authors concluded that there is high-level evidence supporting BoNT-A as an adjunct for the treatment of upper limb spasticity in pediatric patients with cerebral palsy but that it should be combined with occupational therapy. The authors recognized that further study is necessary to identify which children would most benefit from BoNT-A injections as well as the timing and frequency of treatment.
There has been extensive research regarding the nonoperative treatment of spasticity in pediatric patients with cerebral palsy. In the same light, interventions that can improve strength and endurance in these patients are critical as well. Fowler et al.4 examined the effects of a stationary cycling intervention on muscle strength, locomotor endurance, self-selected walking speed, and gross motor function in a study of sixty-two patients (age range, seven to eighteen years; GMFCS I to III) with spastic diplegic cerebral palsy who were able to walk.
In this single-blinded study, patients were randomly assigned to a stationary cycling group or a control group in which no interventions took place. Patients in the cycling group engaged in thirty sessions over a twelve-week period. The primary outcome measures were peak knee extensor and flexor moments, the 600-yard walk-run test, the thirty-second walk test, and the Gross Motor Function Measure sections D and E (GMFM-66). The authors found significant improvement in the 600-yard walk-run test, peak knee extensor moments (at 120°/s), peak knee flexor moments (at 30°/s), and the GMFM-66 in the cycling group when the baseline scores were compared with the post-intervention scores. However, significant differences were not found between the cycling and control groups in terms of the amount of change between the baseline and post-intervention scores, indicating that stationary cycling could not be shown to be more effective than other modalities. The authors concluded that their study provides preliminary evidence that cycling may be an effective intervention.
Jeans et al.5 examined the effect of amputation level on energy expenditure during overground walking by pediatric amputees. Seventy-three pediatric amputees and forty-five control subjects took part in a gait study in which the effects of amputation level on self-selected walking speed and oxygen cost were determined. The parameters that were measured with use of an oxygen analysis telemetry unit were resting VO2 rate (mL/kg/min), resting heart rate (beats per minute [bpm]), walking VO2 rate (mL/kg/min), walking VO2 cost (mL/kg/m), walking heart rate (bpm), and self-selected walking velocity (m/min). The authors found that children with a Syme amputation, transtibial amputation, or knee disarticulation walked with the same speed and oxygen cost as control children in the same age group. Patients with hip disarticulations had reduced walking speed (72% of normal), increased VO2 cost (161% of normal), and increased heart rate (124% of normal) as compared with controls. Patients with unilateral transfemoral amputations also had a significantly reduced walking speed (80% of normal). Bilateral amputees were found to walk significantly slower (87% of normal) and had an elevated heart rate (119% of normal) but similar energy costs as compared with unilateral amputees. The authors concluded that children with amputations through the knee and distal to the knee were able to maintain a normal walking speed without a significantly increased energy cost. Patients with amputation proximal to the knee walked significantly slower and experienced an increased energy cost.
Dynamic electromyography (EMG) and computerized motion analysis are essential tools for providing a basis for many interventions that the orthopaedic clinician utilizes in the operating room and the clinic. Although the reliability of EMG data has been well established for isometric and slow dynamic tasks, the data are limited for the use of EMG for ballistic movements. Fauth et al.6 examined within-session and trial-to-trial reliability of EMG of the quadriceps and hamstring muscles during isometric and ballistic activities. Twenty-four subjects performed two test exercises (such as landing after a depth jump and cutting after a 10-m sprint) three different times. The authors found that all of the intra-class coefficient values (a direct approximation of reliability) were >0.8 (most were >0.90) for surface EMG during the various testing modalities. The results of this study indicated that surface EMG is a reliable and reproducible method for assessing quadriceps and hamstring muscle activation in both isometric activities (which have been traditionally tested) and ballistic/dynamic activities. These are essential data for further studies utilizing this testing modality for the evaluation of athletes.
Continuing in the use of EMG and motion analysis to understand athletic performance and injury, Chumanov et al.7 examined the susceptibility of the hamstring muscles to injury based on the body's position within the gait cycle. Utilizing twelve healthy subjects running on treadmills at speeds of 80% to 100% of maximum, the authors examined whole-body kinematics, EMG activities, and ground-reaction forces to compare hamstring musculotendon stretch, loading, and work done during the stance and swing phases of high-speed running. The authors found that the hamstrings lengthened under load during swing phase and then shortened under load during late swing through stance. Furthermore, the authors found that the biceps femoris loading increased significantly with speed and was greater during swing than stance. The hamstrings performed negative work only during swing phase, with this negative work increasing with speed. The authors suggested that a rehabilitation program that concentrates on eccentric exercises may benefit the patient more than concentric exercise programs.
EMG and motion analysis are essential components of the care of patients with cerebral palsy and are used as a guide to both nonsurgical and surgical intervention. van der Krogt et al.8 examined gastrocnemius and soleus muscle spasticity in patients with cerebral palsy to quantify dynamic spasticity (the coupling between muscle-tendon stretch velocity and muscle activity during gait). Seventeen children with cerebral palsy with spasticity of the gastrocnemius and soleus muscles who were able to walk were compared with eleven matched, healthy children (controls). During walking trials at three different speeds, three-dimensional kinematic and EMG data were collected. In the control group, muscles were stretched fast in swing but did not have any subsequent muscle activity. In contrast, patients with spasticity not only had muscles that stretched more slowly for the same walking speed but then had an increase in muscle activity as well. The mean ratio between peak activity and peak stretch velocity was found to be four times higher in spastic muscles. This ratio was also found to increase with walking speed. Furthermore, in the stance phase of the gait cycle, muscle stretch in healthy control children was followed by an increase in muscle activity. In contrast, spastic muscles in patients with cerebral palsy stretched fast as a result of the loading response, but, because muscle activity was already built up from the swing phase, there was not an increase in muscle activity (dynamic spasticity was not present).
There is a need for all orthopaedic clinicians to have a firm understanding of the principles of amputation and prosthetic placement. There have been several high-quality studies in this area over the past year.
An understanding of the epidemiology of amputation is the basis on which further investigation and analysis arise. Barmparas et al.9 examined the epidemiology of posttraumatic limb amputation through an analysis of the National Trauma Data Bank (version 5), specifically with regard to the outcomes of posttraumatic upper and lower extremity amputations. The authors identified 8910 patients who had had an amputation, representing 1% of all trauma patients. The most common mechanisms of injury were blunt trauma due to motor-vehicle collisions (51.0%), followed by machinery accidents (19.4%). The majority of patients (76.9%) had digital amputations. Of the subset of patients with limb amputations, the majority (92.7%) sustained a single-limb injury, with lower extremity injury (58.9%) being more common than upper extremity injury (41.1%). Patients who had been involved in motor-vehicle collisions had more upper extremity amputations (54.5% compared with 45.5%; p < 0.001), whereas motorcyclists (86.2% compared with 13.8%; p < 0.001) and pedestrians (91.9% compared with 8.1%; p < 0.001) had more lower extremity amputations. Patients with lower extremity amputations were more likely to require discharge to a skilled nursing facility, whereas those with upper extremity amputations were more likely to be discharged home. Multiple limb amputation was an independent risk factor for death, whereas single limb amputation was not.
Multiple studies in the literature have examined the outcomes for patients with amputations, particularly those of the lower limb. However, the reliability of these outcome measures is largely unknown. Resnik and Borgia10, citing difficulty with differentiating true change from statistical error, performed a study examining the reliability of outcome measures for lower-limb amputees. The authors designed a multi-site study to evaluate the following tests: a modified version of the Prosthetic Evaluation Questionnaire (PEQ), scales of a version of the 36-Item Short-Form Health Survey questionnaire adapted for the veteran population (SF-36V), the Orthotics and Prosthetics Users’ Survey (OPUS), the Patient-Specific Functional Scale (PSFS), the Two-Minute Walk Test, the Six-Minute Walk Test, the Timed "Up & Go" Test, and the Amputee Mobility Predictor. The authors examined the test-retest reliability of these tests. In addition, they conducted an item analysis of the modified PEQ. Forty-four patients with unilateral lower-limb amputation participated in the study. Participants engaged in each test twice within a one-week period. The authors found strong test-retest reliability scores for the performance measures mentioned above, indicating that they were good choices for evaluating performance in patients with lower-limb amputation. The authors also found that the PEQ subscales had good reliability, which is comparable with what traditionally has been reported in the literature. Armed with this knowledge, clinicians can have increased confidence in the modalities that they use to assess amputee outcome, both clinically and for research purposes.
Although there have been a multitude of studies examining amputee locomotion, there has been very limited examination of amputee gait during turning, a task that is integral for walking in the household or community. Segal et al.11 compared the gait biomechanics of unilateral transtibial amputees with those of non-amputees during a common turning task at a self-selected speed. Peak internal and external rotation moments of the hip, knee, and ankle; mediolateral ground-reaction impulse; peak effective limb length; and stride length were compared between the two groups and within the amputee group (prosthetic limb versus sound limb) as the subjects walked a circular path with a 1-m radius. The authors found that amputees had decreased internal rotation moments at the prosthetic limb hip and knee compared with non-amputees, indicating a potential means by which amputees can decrease stress on the residual (non-amputated) part. Yet, as a potential consequence of this in late stance, amputees had an increase in sound limb hip external rotation moment in early stance. A longer effective limb length, which could possibly be attributed to trunk shift, was noted in this study.
Two studies last year were important in the field of prosthetic design; both examined new technologies in prosthetics. Tillander et al.12 examined the infectious complications of osseointegrated titanium implants for limb prosthetic attachment. The authors sought to determine the frequency and presentation of infectious complications associated with titanium osseointegrated prostheses. Thirty-nine patients (forty-five implants) with arm and leg amputations who received the transcutaneous titanium osseointegrated implants were prospectively followed. The authors found a 5% peri-implant infection rate at the time of inclusion (six months) and an 18% rate (seven patients) at the time of follow-up (three years). At the time of inclusion (six months), the most common bacteria found at the skin-implant interface were Staphylococcus aureus (sixteen patients, seventeen implants), coagulase-negative staphylococci (ten implants); Streptococcus group B, G, or nontypable (nine implants); Gram-negative rods (four implants), Enterococcus species (three implants), beta-hemolytic Streptococcus group A (one implant), and alfa streptococci (one implant). No methicillin-resistant Staphylococcus aureus (MRSA) was found. In three of seven patients with peri-implant infections who were evaluated at the time of follow-up (three years), cultures of specimens from the skin-implant interface at six months yielded the same species as those at three years.
"Energy storage and return" feet have been developed to store mechanical energy in the prosthesis during early stance to midstance, with subsequent return of this energy to the amputee during late stance and push-off. Ventura et al.13 examined the influence of prosthetic dorsiflexion and energy storage and return on limb loading during steady-state walking. Using the Seattle Lightfoot2 (Seattle Systems, Poulsbo, Washington) as the prosthetic foot, the authors attached a C-shaped articulating ankle (Solidworks; Dassault Systèmes Solidworks, Concord, Massachusetts) with different stiffness levels and in different orientations (forward-facing and reverse-facing). They then performed gait analysis to specifically evaluate ground-reaction forces and intersegmental joint moments and powers. As a result, five different conditions were tested: a solid ankle, a stiff forward-facing ankle, a compliant forward-facing ankle, a stiff reverse-facing ankle, and a compliant reverse-facing ankle. Twelve patients with a unilateral below-the-knee amputation participated in the gait analysis at walking speeds of approximately 1.20 m/s. The authors found that all energy-storing ankles had significantly greater ankle dorsiflexion and increased energy return during late stance when compared with the solid ankles. All energy-storing ankles also decreased residual leg vertical ground-reaction forces in late stance, increased residual leg propulsive ground-reaction force impulses, and increased residual leg knee joint extensor moments. The authors concluded that the results of their study provided insight into the inter-relationships of ankle dorsiflexion, energy storage and return, and limb loading.
Heterotopic ossification is defined as the formation of lamellar bone in nonskeletal tissue. The biochemical and cellular mechanisms, while slowly being elucidated, are still not well defined.
More recently, the high rate of heterotopic bone formation in combat-related extremities has been highlighted by the current conflicts in Iran and Afghanistan14. While a number of recent studies have again emphasized the increased rate of heterotopic ossification in injuries of higher severity and in patients with head injuries, a more striking observation has been the increased heterotopic bone formation in military personnel requiring amputations15,16. In patients managed for long-bone fractures proximal to a traumatic amputation, the rate of heterotopic ossification is high. Gordon et al. reported on the results of internal fixation of long-bone fractures proximal to a traumatic amputation in a study of thirty-seven military members17. While union occurred at the sites of all treated fractures, heterotopic ossification developed in twenty-eight patients (76%). The majority of these patients had heterotopic ossification at both the amputation site and the fracture site. Eleven patients (39%) required operative excision of symptomatic heterotopic bone in this series.
The association between traumatic brain injury and the formation of heterotopic bone within skeletal muscle is well known, but the cellular and biochemical mechanisms responsible for this association are unclear. Cadosch et al. performed an in vitro study in which they compared the response of skeletal muscle cells to serum from patients with traumatic brain injury, patients with a long-bone fracture, and control subjects18. Blood samples were collected from subjects within six hours after the injury and then at twenty-four, seventy-two, and 168 hours after the injury. Human skeletal muscle cells from patients undergoing orthopaedic surgery were isolated and cultured. Proliferation and differentiation of these skeletal muscle cells in response to the three different serum groups were then characterized with various assays. Serum from patients with traumatic brain injury induced proliferation of skeletal muscle cells at a significantly higher rate than serum from patients with a long-bone fracture or from control patients. These results suggest that traumatic brain injury leads to changes in the profile of serum that may lead to proliferation of cells with osteogenic potential within soft tissues.
Clinically, finding a safe and effective method of primary prophylaxis against heterotopic ossification remains a paramount goal, especially in cases of combat-related injuries, in which later excision can lead to complications. In a prospective, randomized study, Hamid et al. demonstrated that radiation therapy can have significant side effects on bone healing and revealed an increased rate of nonunion in patients with elbow fractures that were treated with radiation therapy to prevent heterotopic bone formation19. Forty-eight patients were randomized to a study group (700 cGy of single-fraction radiation therapy) or a control group (no radiation therapy). Patients were followed clinically on the basis of the Mayo Elbow Performance Score, the range of motion of the elbow, fracture-healing on radiographs, the presence of heterotopic ossification, and any adverse events. Power analysis suggested that a total of seventy-three patients per group would be needed, but the study was stopped early because of an unacceptably high rate of nonunion in the radiation therapy group (38%; eight of twenty-one) compared with the control group (4%; one of twenty-four). With the limited number of patients who were enrolled in the study, no other variable was found to be significantly different between the two groups. This study suggested that single-fraction radiation therapy performed postoperatively for elbow trauma to prevent heterotopic bone formation may increase the rate of nonunion in these patients.
In patients with severe elbow trauma, heterotopic bone can form and can limit elbow motion. Surgical release of the posterior band of the medial collateral ligament and excision of heterotopic bone can reliably restore elbow flexion, as described by Park et al.20. In that study, forty (95%) of forty-two patients with <100° of elbow flexion following trauma were observed to have heterotopic ossification intraoperatively, which was a higher rate than was observed on radiographs. The surgical approach described in that study involved release of the posterior band of the medial collateral ligament in all patients as well as anterior procedures in some patients. Ulnar nerve transposition was performed in forty of the forty-two patients. At a mean of thirty-nine months after surgery, there was a significant increase in elbow flexion, from 89° to 124°. Eighty-eight percent of patients regained 120° of elbow flexion-extension and 100° of supination-pronation. The mean Mayo Elbow Performance Index score increased from 73 to 94. That study demonstrated that posttraumatic loss of elbow flexion can usually be attributed to the formation of heterotopic bone and that excision of this bone, along with release of the posterior band of the medial collateral ligament, can restore a satisfactory amount of elbow flexion.
Heterotopic bone also can form in patients affected by burns and can be reliably removed with use of a novel technique described by Maender et al., in which multiple small surgical approaches are used without raising any cutaneous flaps21. In a series of eleven elbows in nine patients who were affected by direct thermal injury, this multiple-approach surgical technique followed by radiation therapy improved elbow motion and function with few complications.
Current neuroprotective treatments for spinal cord injury continue to be controversial, and new therapies, such as cerebrospinal fluid drainage and a number of pharmaceutical agents, continue to emerge. A recent study by Ito et al. on the use of methylprednisolone provides conflicting evidence to the National Acute Spinal Cord Injury Studies (NASCIS), in which the use of methylprednisolone was supported22. In this prospective study, thirty-eight consecutive patients with cervical spinal cord injury during a two-year period were managed with methylprednisolone within eight hours according to the NASICS-2 protocol. During the following two-year period, forty-one consecutive patients with similar injuries were managed without the use of methylprednisolone. American Spinal Injury Association (ASIA) impairment and motor scores were collected at the time of admission and three months after the injury, and complications were noted. An increase of at least one clinical grade of the ASIA impairment score was observed in 63% of the patients in the no-steroid group, compared with 45% of those in the steroid group; this difference was not significant. Similarly, the difference in improvement in the ASIA motor score was not significant between the no-steroid group (13.8 points) and the steroid group (12.4 points). However, the complication rate was significantly higher in the steroid group. Infectious complications (urinary tract infections, wound infection, pneumonia) occurred in 68% of the patients in the steroid group, compared with 44% of the patients in the no-steroid group (p = 0.028). The prevalence of pneumonia was significantly higher in the steroid group, particularly among patients with complete motor loss. The rate of gastrointestinal hemorrhage was also higher in the steroid group, although the difference was not significant. That study suggested that the use of high-dose methylprednisolone should be limited because of its questionable efficacy and high rate of pulmonary complications.
Regaining hand and arm function is a high priority for patients with tetraplegia. A recent study demonstrated that limited shoulder motion at time of discharge led to a lower Functional Independence Measure (FIM) score and an inability to perform independent transfers one year after discharge23. Mulroy et al. performed a randomized controlled trial to determine whether an exercise program focused on performing upper extremity tasks would lead to improvements in terms of shoulder pain and function24. This twelve-week home-based program focused on shoulder strengthening and stretching exercises as well as instructions on optimizing transfers, raises from a sitting position, and wheelchair propulsion. Patients who participated in the home-based program had improvements in terms of shoulder pain, muscle strength, activity, and quality of life as compared with a control group of patients who viewed an hour-long educational video.
Restoring the ability to extend the elbow after spinal cord injury allows for increased function, including wheelchair propulsion and independent transfers. Kozin et al. reviewed patient satisfaction and strength in a study of sixty-eight arms in forty patients undergoing biceps-to-triceps transfers25. The biceps tendon is released from the radial tuberosity and then is transferred around the medial aspect of the arm into a split in the triceps and is docked into a unicortical olecranon hole. Preoperative and postoperative manual muscle-testing demonstrated a significant increase in muscle strength. Seventy-five percent of the arms had overhead function (muscle strength, 3 of 5). Patient performance and satisfaction were measured with use of the Canadian Occupational Performance Measure and were found to be greatly improved; however, complete data were collected for only eight patients. Complications included eleven ruptured and/or attenuated transfers during rehabilitation. There was also one postoperative infection, one postoperative hematoma, and one unrecognized compartment syndrome. The authors concluded that the biceps-to-triceps transfer is a reliable technique for restoring elbow extension in patients with tetraplegia.
Similarly, regaining hand function relies on rehabilitation and surgical procedures improving grip strength and range of motion for general activities of daily living. Wangdell and Fridén reported on patient satisfaction and performance after grip reconstruction in a study of twenty-two arms in twenty patients with tetraplegia26. At a mean of 7.3 years after the injury, these patients underwent grip reconstruction for both finger and thumb flexion. This included transfer of the brachioradialis to the flexor pollicis longus, transfer of the extensor carpi radialis longus to the flexor digitorum profundi, and a split tenodesis of the flexor pollicis longus to the extensor pollicis longus. The mean Canadian Occupational Performance Measure score improved from 2.5 preoperatively to 6 at both six and twelve months postoperatively; this magnitude of improvement represents a clinically important change. Activities of domestic life, eating, and leisure showed the greatest improvements in terms of performance and satisfaction. Postoperative rehabilitation requires relearning functional hand tasks by switching from utilizing a passive tenodesis grip to utilizing active hand function.
Each year, at the AAOS Specialty Day, the Orthopaedic Rehabilitation Association (ORA) announces the Jacqueline Perry Award for the best scientific work submitted that year related to musculoskeletal rehabilitation.
In this year's Jacqueline Perry Award paper, entitled "Outcomes of Tendon Lengthenings in Spastic Hemiparetics with Intact Motor Control and Shoulder Contractures," Namdari et al.27 evaluated the outcomes of shoulder tendon fractional lengthenings in patients with spasticity and preserved volitional control. A consecutive series of thirty-four adults with spastic hemiparesis resulting from upper motor neuron injury following a stroke (twenty-three patients) or a traumatic brain injury (eleven patients) who had limited shoulder movement with preserved volitional motor control and who underwent shoulder tendon lengthenings were evaluated. Active and passive shoulder motion, spasticity, pain, and satisfaction were considered preoperatively and postoperatively. The study group included fifteen males and nineteen females with a mean age of 44.1 years. The mean duration of follow-up was 12.2 months. The mean modified Ashworth spasticity score was 2.4 preoperatively and 1.9 postoperatively (p = 0.001). Active flexion, abduction, and external rotation improved from 33%, 32%, and 7%, respectively, to 64%, 60%, and 52%, respectively, compared with the normal, contralateral side (p < 0.001). Similarly, passive extension, flexion, abduction, and external rotation improved from 65%, 47%, 54%, and 32%, respectively, to 89%, 73%, 69%, and 64%, respectively, compared with the normal, contralateral side (p < 0.01). Fifteen (94%) of sixteen patients with preoperative pain had pain relief postoperatively, with fourteen (88%) being pain-free. Thirty-one patients (91%) were satisfied with the outcome. The authors concluded that shoulder tendon lengthenings can be an effective means of pain relief, improved motion, enhanced active motor function, and decreased spasticity in patients with spastic hemiparesis resulting from upper motor neuron injury.
Several original scientific studies were presented at the ORA Specialty Day at the 2011 American Academy of Orthopaedic Surgeons Annual Meeting in San Diego, California.
Hosalkar et al.28 presented a study related to remodeling of lateral acetabular coverage following triple innominate osteotomy in children with Legg-Calvé-Perthes disease. Twenty osteotomies were performed in nineteen consecutive children with Herring lateral pillar group B Legg-Calvé-Perthes disease. Sequential radiographs were assessed by two blinded board-certified and fellowship-trained pediatric orthopaedic surgeons, with two sets of readings done more than two weeks apart. The center-edge angle of Wiberg, Sharp angle, and acetabular roof angle were measured. Statistical analysis was conducted. On the basis of this analysis, 43.5° was derived as the ideal center-edge angle to prevent pincer impingement at the time of the latest follow-up, with a sensitivity of 100% and specificity of 69.2%. No patient with a roof arc of greater than −6° had a negative roof arc at the time of the latest follow-up. The average postoperative Sharp angle for patients in whom the femoral head was overcovered (Sharp angle, ≤28°) was 23.7°, compared with 29.8° for those in whom it was not overcovered (p < 0.00; Mann Whitney U test). Interrater and test-retest reliability were excellent. The authors concluded that triple innominate osteotomy resulted in containment and maintenance of femoral head sphericity. Lateral coverage remodels with time in all cases, but overzealous correction should be avoided. Correction should not exceed a center-edge angle of 43.5°, an acetabular roof angle of −6°, and a Sharp angle of <30° to allow remodeling to a mechanically sound, well-contained hip with no impingement.
Steppacher et al.29 presented a review of seventy-eight patients (ninety-seven hips) who underwent surgery for the treatment of symptomatic femoroacetabular impingement. Eight hips (8%) had pincer-type femoroacetabular impingement, eight hips (8%) had cam-type femoroacetabular impingement, and eighty-one hips (84%) had a combined form of femoroacetabular impingement. The mean age at the time of the operation was 31.6 years (range, fifteen to fifty-two years). The mean duration of follow-up (and standard deviation) was 6.0 ± 0.5 years (range, 5.0 to 7.1 years). Survival and predictive factors were calculated with conversion to a total hip arthroplasty, progression of osteoarthrosis, or a Merle d'Aubigné score of ≤14 as the end points. The Merle d'Aubigné score increased significantly, from 15.3 ± 1.4 (range, 9 to 15) preoperatively to 17.2 ± 1.2 (range, 12 to 18) postoperatively, because of improvement in terms of pain (p < 0.001). The mean Tönnis score did not change significantly (p = 0.21). Eighty-three hips (86%) remained unchanged in terms of radiographic outcome, seven hips (7%) showed progression of osteoarthrosis, and seven hips (7%) were treated with conversion to a total hip arthroplasty. Fifteen hips (15%) reached an end point: seven hips were converted to a total hip arthroplasty, seven hips showed progression of osteoarthrosis, and one hip had a Merle d'Aubigné score of ≤14. This resulted in a cumulative survival rate of 90.7% (95% confidence interval, 84.9% to 96.5%) at five years. There were eleven predictive factors for poor outcome, including demographic factors (age, weight, body-mass index [BMI]), two preoperative factors (osteoarthrosis, anterior femoral coverage), and six postoperative radiographic factors describing decreased acetabular coverage. The cumulative five-year survival rate, for all end points, was > 90% after surgical hip dislocation with labral refixation for the treatment of femoroacetabular impingement. Ninety-one percent of the hips showed no progression of osteoarthrosis at the time of the five-year follow-up. Negative predictive factors influencing the outcome were age, BMI, preoperative arthritis, and overcorrection resulting in iatrogenic acetabular dysplasia. Overcorrection with a resulting insufficiency of femoral head coverage leads to early deterioration of the joint.
Hosalkar and Siebenrock30 presented their series of young adults with symptomatic femoroacetabular impingement following in situ pinning for the treatment of mild slipped capital femoral epiphysis during childhood. This study was a long-term follow-up of mild slipped capital femoral epiphysis treated in the past with in situ pinning with correlation of intraoperative findings noted during open surgery. The authors hypothesized (1) that even mild slips that undergo in situ pinning can present with symptomatic femoroacetabular impingement or osteoarthritis with time and (2) that the severity of changes correlates with the duration of symptoms. This series included patients with symptomatic femoroacetabular impingement who underwent open surgical dislocation for hip preservation as well as patients who underwent primary total hip arthroplasty for the treatment of advanced changes of arthritis. Intraoperative observations with detailed descriptions of the status of the femoral head, acetabular cartilage, and labrum, including the subtype of femoroacetabular impingement, were reviewed and reported. A new working classification was established to grade the severity of intraoperative morphologic damage. Fifty-five patients with a history of mild slipped capital femoral epiphysis and in situ pinning in the past underwent surgical procedures for the treatment of symptomatic hip problems. The mean age at the time of initial in situ pinning was 11.6 years. Twenty-three of these fifty-five patients had severe damage of the labrum and acetabular cartilage, changes of mixed femoroacetabular impingement, and advanced osteoarthritis and underwent primary total hip arthroplasty at a mean age of 29.3 years (range, sixteen to thirty-nine years). Twenty-eight patients (thirty-three hips) underwent open surgical dislocation for the treatment of symptomatic femoroacetabular impingement. The mean age at the time of surgery for the treatment of femoroacetabular impingement was 24.3 years. Twenty hips had predominantly cam-type lesions, and thirteen had mixed lesions. The severity of articular damage correlated well with the duration between pinning and open surgery and also with the duration of symptomatic femoroacetabular impingement (p < 0.001 for labral damage and p = 0.002 for acetabular cartilage damage). The authors concluded that even mild slips that undergo pinning in situ have abnormal morphology and can develop symptomatic femoroacetabular impingement with time or advanced arthritis necessitating total hip arthroplasty.
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