Radiation therapy for preventing recurrence of neurogenic heterotopic ossification

Radiation therapy is commonly used to prevent heterotopic ossification, and the dose-dependent effects of this treatment have been well documented in patients after total hip arthroplasty (THA). However, the efficacy and dose requirement of radiation therapy to prevent heterotopic ossification of nonsurgical origin have not been studied. The purpose of this retrospective case-control study was to determine the effects of prophylactic radiation therapy on severe heterotopic ossification recurrence, postoperative range of motion (ROM), and wound healing in patients with heterotopic ossification secondary to neurologic deficits. Selection was not blinded, and higher risk patients were generally assigned to the treatment group. Standard doses of radiation therapy did not adequately lower recurrence rates; in fact, there was a higher incidence of heterotopic ossification formation necessitating revision in the treatment group (15.0%) compared to the control group (5.1%). Moreover, patients who received radiation therapy were not more successful at maintaining intraoperative ROM over time. There was a similar incidence of delayed wound healing between groups (12.8% in the control group and 12.5% in the treatment group), and no other negative side effects or complications were observed. These results suggest that the 700 cGy dose of radiation therapy typically used for the prophylaxis of heterotopic ossification associated with THA does not effectively prevent the recurrence of neurogenic heterotopic ossification in high-risk patients. Further studies are needed to determine whether higher doses of radiation therapy will provide more effective prophylaxis for heterotopic ossification.

Fixation techniques for split anterior tibialis transfer in spastic equinovarus feet

Equinovarus of the foot is the most common lower extremity deformity following traumatic brain injury. We evaluated outcomes of the split anterior tibialis tendon transfer (SPLATT) for correction of equinovarus in 47 patients with hemiplegic traumatic brain injury and specifically studied differences in outcomes with two tendon fixation techniques. Seventeen patients constituting Group I underwent fixation with one technique and 30 constituting Group II had another technique. Patients in both groups had appropriate procedures based on dynamic electromyography and gait analyses. Both groups were demographically comparable. All 47 feet were corrected to plantigrade position. Thirty-six of 47 patients became brace-free at final followup. There was a notable decrease in the use of ambulatory aids and ambulatory status improved in both groups. There were three fixation-related complications in Group I and none in Group II. Surgical correction of the spastic equinovarus with SPLATT, in the appropriate patient, with or without associated tendon procedures helps to achieve and maintain correction, improves the ambulatory status of the patient, and eliminates the need for bracing in as much as 77% of patients. We recommend the Group II construct owing to the considerably lower complication rate.

Musculoskeletal pain in polio survivors and strength-matched controls

OBJECTIVES

To determine whether a significant difference exists between musculoskeletal symptoms of polio survivors and those of older adults with no history of polio, and to determine if activity level and strength predict pain in either group.

DESIGN

Matched research design.

SETTING

A research laboratory in a rehabilitation setting.

PARTICIPANTS

Fifty-four polio survivors and 54 adults with no history of polio were matched for gender, race, and bilateral knee extensor strength and selected from a cohort of 316 subjects who participated in a study on the relation between activity level and health status.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Location and severity of musculoskeletal pain, activity frequency and intensity level, maximum voluntary isometric strength, and physical performance measures.

RESULTS

Polio survivors reported significantly more symptoms than the matched controls ( P <.05). Symptom status among the polio survivors was strongly associated with performance strain, perceived exertion, and activity intensity. Although the polio survivors had activity frequencies and habitual walking speeds that were similar to those from the matched controls, there was evidence that they performed activities at higher intensity levels.

CONCLUSIONS

Activity level is a factor in the development of musculoskeletal symptoms in polio survivors. Polio survivors who perform at higher intensity levels are more likely to have moderate to severe pain and more mobility difficulties.

The influence of dynamic polyelectromyography in formulating a surgical plan in treatment of spastic elbow flexion deformity

OBJECTIVE

To determine the influence of motor-control analysis with dynamic electromyography on surgical planning in patients with spastic elbow flexion deformity.

DESIGN

Prospective observational design.

SETTING

A Traumatic Brain Injury Model Systems-affiliated specialty referral center for the evaluation and treatment of mobility problems associated with neurologic injury and disease.

PARTICIPANTS

Twenty-one patients with spastic elbow flexion deformity.

INTERVENTIONS

Two surgeons each formulated a detailed surgical plan for each individual muscle-tendon unit. Patients then underwent motor-control analysis in which kinetic and polyelectromyographic data were collected by using a standard protocol. Each surgeon formulated another surgical plan after independently reviewing the laboratory study.

MAIN OUTCOME MEASURES

The frequency of change and degree of agreement in the surgical plans after review of the laboratory data were used as measures of the effect of the laboratory studies.

RESULTS

Fifty-seven percent of the surgical plans were changed after the motor-control study. The frequency of change did not differ by clinical experience. There was a trend toward higher agreement between surgeons after the study than before.

CONCLUSIONS

Detailed electromyographic motor-control analysis alters surgical planning for patients with spastic elbow flexion deformity. Clinical assessment alone does not accurately identify the muscles responsible for the deformity or dysfunction. More clinical experience does not result in greater accuracy. Motor-control analysis produces higher agreement between surgeons in planning surgery.

A comparison of the effects of exercise and lifestyle modification on the resolution of overuse symptoms of the shoulder in polio survivors: a preliminary study

OBJECTIVE

To compare the effectiveness of exercise and lifestyle modification therapy in treating shoulder symptoms in polio survivors with lower-extremity weakness.

DESIGN

A randomized parallel group study.

SETTING

Research laboratory.

PARTICIPANTS

Twenty-three subjects recruited from a cohort of 194 polio survivors who had participated in a previous study had bilateral hip-extensor and knee-extensor weakness and reported experiencing shoulder pain on a regular basis with daily activity.

INTERVENTIONS

Subjects were randomly assigned to 1 of 3 treatment groups. Members of group 1 were placed on a home exercise program that focused on strengthening their hip and knee extensors. Members of group 2 were instructed in lifestyle modification techniques designed to avoid shoulder overuse. Members of group 3 received both interventions.

MAIN OUTCOME MEASURES

Shoulder symptoms were quantified in terms of number and severity. Isometric strength of bilateral hip and knee extensors was measured with a hand-held dynamometer.

RESULTS

Symptoms improved in all 3 groups. However, members of the exercise-only group (group 1) were the only ones to show a significant difference in both number and severity of symptoms when pre- and posttreatment values were compared.

CONCLUSIONS

Both exercise and lifestyle modification therapies that focus on reducing the stress related to lower-extremity weakness are effective in treating shoulder overuse symptoms in polio survivors. A trend toward greater improvement in shoulder symptoms in subjects who participated in the exercise program and who also showed a trend toward increased knee-extensor strength supports muscle strength and/or endurance as a key factor.

Changes in strength over time among polio survivors

OBJECTIVE

To study changes in the strength of different muscle groups in polio survivors over a period of approximately 9 months.

DESIGN

Longitudinal study.

SETTING

Moss Rehabilitation Research Institute.

PARTICIPANTS

One hundred twenty subjects (57 men, 63 women) were studied on three occasions, each 3 to 5 months apart. Subjects were recruited through the Einstein-Moss Post-Polio Management Program. newspaper advertisements, and polio support groups.

MAIN OUTCOME MEASURES

Isometric strength of 30 muscle groups (16 in upper extremities, 14 in lower extremities) was measured, using a hand-held dynamometer.

RESULTS

Data were analyzed in two separate groups: upper-extremity muscles and lower-extremity muscles. Results for the upper-extremity muscles revealed evidence of a significant deterioration in strength. The amount of deterioration differed among muscles and increased with age. There was also evidence of deterioration in strength in the flexor muscles in the ankle, hip, and knee. However, the rate of deterioration in these muscles was not strongly related to age, time since polio, gender, symptom status, or history of residual weakness.

CONCLUSIONS

Strength is deteriorating among polio survivors at a rate higher than that associated with normal aging. This deterioration is not occurring in the extensor, or so-called "weight-bearing" muscles, but is occurring in many of the upper-extremity muscle groups and in the flexor muscles in the lower extremities.

The relation between lower extremity strength and shoulder overuse symptoms: a model based on polio survivors

OBJECTIVE

To determine the relation between lower extremity weakness and shoulder overuse symptoms among polio survivors. We predicted that individuals with moderate weakness in their leg extensor muscles would use their arms to help compensate for this weakness and would be at high risk for developing symptoms of shoulder overuse.

DESIGN

A cohort study of polio survivors recruited from the Einstein-Moss Postpolio Management Program (Philadelphia), the community, and the surrounding region.

SETTING

A research laboratory at Moss Rehabilitation Research Institute, Philadelphia, PA.

PARTICIPANTS

One hundred ninety-four polio survivors. Demographic and medical history data, symptom data, and strength data were obtained for each.

MAIN OUTCOME MEASURES

Presence or absence of shoulder symptoms and ratings of pain by visual analogue scale were recorded. Strength was measured using a hand-held dynamometer and manual muscle testing.

RESULTS

Shoulder symptoms could be grouped into two distinct clusters based on the type of testing used for assessment. Symptoms elicited by palpation were present in 26% of the subjects and were strongly related to knee extensor strength and weight. These symptoms were more common among women than men (42% and 10%, respectively). Symptoms elicited by resistance tests were present in 33% of the subjects and were seen with equal frequency in both sexes. These symptoms were also related to lower extremity strength, but the specific relationship was not as clear as for the palpation-related symptoms.

CONCLUSIONS

Lower extremity weakness predisposes individuals to shoulder overuse symptoms. Sex and body weight are contributing factors. These results may be generalized to other populations with lower extremity weakness, including the elderly.

Improving calf muscle strength in patients with spastic equinovarus deformity by transfer of the long toe flexors to the Os calcis

The split tibialis anterior tendon transfer (SPLATT), Achilles tendon lengthening, and toe flexor release are proven and effective procedures for correcting a spastic equinovarus deformity of the foot. Paresis is a prominent feature of upper motoneuron syndrome. Lengthening the Achilles tendon, although necessary to correct the equinus, further weakens the gastrocnemius-soleus muscle group. The calf paresis commonly results in the need for an ankle-foot orthosis (AFO) during ambulation. Previous studies have shown that despite the correction of the equinovarus deformity, only one third of patients were able to ambulate without an AFO. The need for continued use of an AFO was because of insufficient calf strength to stabilize the tibia during late stance when the body mass is anterior to the ankle joint. This study prospectively evaluated the results of transfer of the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) to the os calcis in 30 patients. The transfer was done in an effort to augment the strength of the gastrocnemius-soleus muscle complex. Twenty-five patients in group I (the control group) underwent SPLATT, Achilles tendon lengthening, and toe flexor release. Thirty patients in group II (the study group) underwent the identical procedures plus the additional FHL and FDL transfer to the os calcis. Postoperatively, the varus and toe flexion deformities were corrected in all feet. In group II, two feet had a mild residual equinus that did not interfere with ambulation. Of the 11 patients who were not independent community ambulators in group I, 7 (64%) improved ambulatory status by at least one level after surgery. Of the 15 patients who were not independent community ambulators in group II, 14 (93%) improved ambulatory status by at least one level after surgery. In group I, 10 of 25 (40%) of the patients were brace free at follow-up. In group II, 21 of 30 (70%) were brace free at follow-up (c2, P =.025). These results indicate that the addition of an FHL and FDL transfer to the os calcis at the time of SPLATT, Achilles tendon lengthening, and toe flexor release improves calf strength and allows greater increase in function and less reliance on orthotics.

Volkmann's ischemic contracture of the upper extremity

Upper extremity deformity of ischemic contracture usually includes elbow flexion, forearm pronation, wrist flexion, thumb flexion and adduction, digital metacarpophalangeal joint extension, and interphalangeal joint flexion. Treatment of mild contractures consists of either nonoperative management with a comprehensive rehabilitation program (to increase range of motion and strenght) or operative management consisting of infarct excision or tendon lengthening. Treatment of moderate-to-severe contractures consists of release of secondary nerve compression, treatment of contractures (with tendon lengthening or recession), tendon or free-tissue transfers to restore lost function, and/or salvage procedures for the severely contracted or neglected extremity.

Correction of severe spastic flexion contractures in the nonfunctional hand

The superficialis to profundus transfer has been a time-honored treatment of spasticity in nonfunctional hands, but it does not address the many associated problems. Fourteen patients were treated with 15 procedures (1 bilateral) designed to relieve severe flexion contractures of the hand and wrist over a 3-year period with a single-stage comprehensive surgical correction consisting of superficialis to profundus transfer, wrist flexor release, flexor pollicis longus lengthening, wrist arthrodesis, carpal tunnel release, and ulnar motor branch neurectomy or intrinsic release. For all, nonoperative treatment had failed or there were chronic skin problems. The follow-up period averaged 1 year. In 13 of 15 patients, there was wrist fusion after the index procedure, with 1 patient requiring replating and another uniting after prolonged casting. Two patients had a residual claw hand with only partial correction of a thumb-in-palm deformity. All preoperative hygiene problems and infections resolved. The comprehensive protocol allowed correction of severe contractures of the hand and wrist by a single operation with improved care and appearance of the hand.

Skin surface pressures under short leg casts

Electronic sensors were used to measure skin surface pressures beneath plaster and fiberglass short leg casts. Pressures were recorded after casting, univalving, bivalving, and spreading of casts. Fiberglass resulted in significantly higher pressures than plaster. Beneficial effects of bivalving and cast spreading are confirmed by significant pressure drops. Application of casts by different orthopaedic surgeons and technologists showed pressure differences due to operator technique. However, fiberglass pressures again proved to be significantly greater than those caused by plaster. Excessive pressure beneath casts can cause skin ulceration, and results confirm the need for extreme care, especially when using fiberglass. It is suggested that plaster is safer than fiberglass when significant extremity swelling is likely or when a patient's skin is more vulnerable to breakdown.

Using dynamic electromyography to guide surgical treatment of the spastic upper extremity in the brain-injured patient

Upper extremity deformity after brain injury is frequently complex and dominated by spasticity or contracture. Clinical examination of the limb is often difficult and inaccurate. Dynamic electromyography provides valuable information previously unobtainable. Analysis of this data can facilitate appropriate reconstruction of the deformed limb.

Deep-venous thrombosis of the upper extremity after traumatic brain injury

Deep-venous thrombosis (DVT) of the lower extremity occurs frequently in a variety of patients, including those with traumatic brain injury (TBI), during their rehabilitation. Thrombosis of the major veins of the upper extremity is believed to be relatively rare, although it has increased in recent years due to the routine use of indwelling percutaneous central venous catheters. Upper extremity pain and swelling in a TBI patient is commonly attributed to heterotopic ossification, reflex sympathetic dystrophy, or occult fracture. Clinicians may not consider DVT in the differential diagnosis. No longer regarded as a benign disorder, we report the successful outcome in a 27-year-old with TBI who developed an upper extremity DVT after subclavian catheterization. The diagnostic findings, as well as treatment recommendations are reviewed.

Valgus deformities of the feet and characteristics of gait in patients who have rheumatoid arthritis

To investigate the cause of valgus deformity of the hindfoot in patients who have rheumatoid arthritis and to characterize the effects of the deformity on gait, two groups of patients were evaluated clinically, radiographically, and with gait analysis in the laboratory. Group 1 consisted of seven patients who had seropositive rheumatoid arthritis and normal alignment of the feet and Group 2, of ten patients who had rheumatoid arthritis and valgus deformity of the hindfoot. In Group 2, the disease was of longer duration and the feet were more painful than in Group 1. There was no evidence of muscular imbalance, equinus contracture, valgus deformity of the tibiotalar joint, or isolated deficiency of the tibialis posterior (such as weakness, tenosynovitis, or rupture of the tendon) that could have contributed to the development of the valgus deformity. In the patients who had valgus deformity, quantitated electromyography demonstrated that the intensity and duration of activity of the tibialis posterior was significantly increased, apparently in an effort to support the collapsing longitudinal arch of the foot. Gait studies revealed decreases in velocity, stride length, and single-limb-support time, as well as delayed heel-rise in both groups, but the decreases were more marked in the patients who had valgus deformity. The results of this study suggest that valgus deformity of the hindfoot in rheumatoid patients results from exaggerated pronation forces on the weakened and inflamed subtalar joint. These forces are caused by alterations in gait secondary to symmetrical muscular weakness and the effort of the patient to minimize pain in the feet. Radiographs also suggested an association between the valgus deformity of the feet and valgus deformity of the knees in patients who have rheumatoid arthritis.