Contributions of biarticular myogenic components to the limitation of the range of motion after immobilization of rat knee joint

BACKGROUND

Muscle atrophy caused by immobilization in the shortened position is characterized by a decrease in the size or cross-sectional area (CSA) of myofibers and decreased muscle length. Few studies have addressed the relationship between limitation of the range of motion (ROM) and the changes in CSA specifically in biarticular muscles after atrophy because of immobilization. We aimed to determine the contribution of 2 distinct muscle groups, the biarticular muscles of the post thigh (PT) and those of the post leg (PL), to the limitation of ROM as well as changes in the myofiber CSAs after joint immobilization surgery.

METHODS

Male Wistar rats (n = 40) were randomly divided into experimental and control groups. In the experimental group, the left knee was surgically immobilized by external fixation for 1, 2, 4, 8, or 16 weeks (n = 5 each) and sham surgery was performed on the right knee. The rats in the control groups (n = 3 per time point) did not undergo surgery. After the indicated immobilization periods, myotomy of the PT or PL biarticular muscles was performed and the ROM was measured. The hamstrings and gastrocnemius muscles from the animals operated for 1 or 16 weeks were subjected to morphological analysis.

RESULTS

In immobilized knees, the relative contribution of the PT biarticular myogenic components to the total restriction reached 80% throughout the first 4 weeks and decreased thereafter. The relative contribution of the PL biarticular myogenic components remained <20% throughout the immobilization period. The ratio of the myofiber CSA of the immobilized to that of the sham-operated knees was significantly lower at 16 weeks after surgery than at 1 week after surgery only in the hamstrings.

CONCLUSIONS

The relative contribution of the PT and PL components to myogenic contracture did not significantly change during the experimental period. However, the ratio of hamstrings CSAs to the sham side was larger than the ratio of medial gastrocnemius CSAs to the sham side after complete atrophy because of immobilization.

The thrower's shoulder

Throwers, or athletes who engage in repetitive overhead motions, are a unique subset of athletes that experience distinct shoulder injuries. Athletes engaged in baseball comprise the majority of patients seeking orthopedic care for throwing related injuries. Injuries specific to throwers most commonly involve the labrum and the undersurface of the rotator cuff. In addition, tissue changes in both the anterior and posterior glenohumeral capsule are common with repetitive overhead motions. These capsular changes alter. This article will examine the pathomechanics of injuries to throwers, elaborate means of diagnoses of cuff and labral injury and discuss recent advances in both non-operative and operative interventions, including preventative principles.

Treatment of camptodactyly using injection of botulinum neurotoxin

BACKGROUND

Camptodactyly is usually painless, not caused by trauma, often appearing bilaterally, gradually progressive flexion contracture of the proximal interphalangeal joint mainly on the 5th fingers.

OBJECTIVES

The aim of the study was to analyze the efficacy injecting botulinum neurotoxin in short muscles of the hand responsible for the contraction of the proximal interphalangeal joint.

MATERIAL AND METHODS

The clinical material consisted of 12 patients (8 women, 4 men) treated with injections of botulinum neurotoxin in 2009-2012. Patients were monitored respectively for 2 weeks, 3 and 6 months and then every six months after the procedure. The observation period after injection of toxin ranged from 18 to 36 months. Our proposed method of treatment is inducing a temporary paralysis of muscles (lumbrical, interosseous) by means of botulinum neurotoxin (Botox).

RESULTS

In the majority (10) of patients an improvement and stabilization was achieved just after one injection and there were no disease progression in subsequent controlled studies. These patients continued treatment with usage of redressing extensive splints. In case of the other two patients it was required to repeat the injections.

CONCLUSIONS

The preliminary results obtained are promising. This method of treatment requires further studies and long-term follow-ups every six months until release of symptoms of the disease will be achieved. The operative treatment is reserved for severe deformities.

Mutations in FAM111B cause hereditary fibrosing poikiloderma with tendon contracture, myopathy, and pulmonary fibrosis

Congenital poikiloderma is characterized by a combination of mottled pigmentation, telangiectasia, and epidermal atrophy in the first few months of life. We have previously described a South African European-descent family affected by a rare autosomal-dominant form of hereditary fibrosing poikiloderma accompanied by tendon contracture, myopathy, and pulmonary fibrosis. Here, we report the identification of causative mutations in FAM111B by whole-exome sequencing. In total, three FAM111B missense mutations were identified in five kindreds of different ethnic backgrounds. The mutation segregated with the disease in one large pedigree, and mutations were de novo in two other pedigrees. All three mutations were absent from public databases and were not observed on Sanger sequencing of 388 ethnically matched control subjects. The three single-nucleotide mutations code for amino acid changes that are clustered within a putative trypsin-like cysteine/serine peptidase domain of FAM111B. These findings provide evidence of the involvement of FAM111B in congenital poikiloderma and multisystem fibrosis.

Amount of torque and duration of stretching affects correction of knee contracture in a rat model of spinal cord injury

BACKGROUND

Joint contractures are a common complication of many neurologic conditions, and stretching often is advocated to prevent and treat these contractures. However, the magnitude and duration of the stretching done in practice usually are guided by subjective clinical impressions.

QUESTIONS/PURPOSES

Using an established T8 spinal cord injury rat model of knee contracture, we sought to determine what combination of static or intermittent stretching, varied by magnitude (high or low) and duration (long or short), leads to the best (1) improvement in the limitation in ROM; (2) restoration of the muscular and articular factors leading to contractures; and (3) prevention and treatment of contracture-associated histologic alterations of joint capsule and articular cartilage.

METHODS

Using a rat animal model, the spinal cord was transected completely at the level of T8. The rats were randomly assigned to seven treatment groups (n = 4 per group), which were composed of static or intermittent stretching in combination with different amounts of applied torque magnitude and duration. We assessed the effect of stretching by measuring the ROM and evaluating the histologic alteration of the capsule and cartilage.

RESULTS

Contractures improved in all treated groups except for the low-torque and short-duration static stretching conditions. High-torque stretching was effective against shortening of the synovial membrane and adhesions in the posterosuperior regions. Collagen Type II and VEGF in the cartilage were increased by stretching.

CONCLUSIONS

High-torque and long-duration static stretching led to greater restoration of ROM than the other torque and duration treatment groups. Stretching was more effective in improving articular components of contractures compared with the muscular components. Stretching in this rat model prevented shortening and adhesion of the joint capsule, and affected biochemical composition, but did not change morphologic features of the cartilage.

CLINICAL RELEVANCE

This animal study tends to support the ideas that static stretching can influence joint ROM and histologic qualities of joint tissues, and that the way stretching is performed influences its efficacy. However, further studies are warranted to determine if our findings are clinically applicable.

Body composition, muscle strength, and physical function of patients with Bethlem myopathy and Ullrich congenital muscular dystrophy

OBJECTIVE

To determine the contributions of body mass, adiposity, and muscularity to physical function and muscle strength in adult patients with Bethlem myopathy (BM) and Ullrich congenital muscular dystrophy (UCMD).

MATERIALS AND METHODS

Evaluation involved one UCMD and 7 BM patients. Body composition was determined by body mass index (BMI) and dual-energy-X-ray-absorptiometry (DXA), muscle strength by dynamometry, physical function by the distance walked in 6 minutes (6MWD), forced vital capacity (FVC) by a spirometer.

RESULTS

Six participants were of normal weight and 2 overweight based on BMI; all were sarcopenic based on appendicular fat free mass index (AFFMI); and 7 were sarcopenic obese based on AFFMI and % fat mass. Average muscle strength was reduced below 50% of normal. The 6MWD was in BM patients 30% less than normal. FVC was reduced in 4 of the BM patients. Muscle strength had a good correlation with the physical function variables. Correlation between muscle strength and BMI was poor; it was very high with AFFMI. AFFMI was the best single explicator of muscle strength and physical function.

CONCLUSION

Muscle mass determined by DXA explains most of the variability of the measures of muscle strength and physical function in patients with BM and UCMD.

Spatiotemporal disorder in the axial skeleton development of the Mesp2-null mouse: a model of spondylocostal dysostosis and spondylothoracic dysostosis

Spondylocostal dysostosis (SCDO) is a genetic disorder characterized by severe malformation of the axial skeleton. Mesp2 encodes a basic helix-loop-helix type transcription factor that is required for somite formation. Its human homologue, Mesp2, is a gene affected in patients with SCDO and a related vertebral disorder, spondylothoracic dysostosis (STDO). This work investigated how the loss of Mesp2 affects axial skeleton development and causes the clinical features of SCDO and STDO. We first confirmed, by three-dimensional computed tomography scanning, that Mesp2-null mice exhibited mineralized tissue patterning resembling the radiological features of SCDO and STDO. Histological observations and in situ hybridization probing for extracellular matrix molecules demonstrated that the developing vertebral bodies in Mesp2-null mice were extensively fused with rare insertions of intervertebral tissue. Unexpectedly, the intervertebral tissues were mostly fused longitudinally in the vertebral column, instead of exhibiting extended formation, as was expected based on the caudalized properties of Mesp2-null somite derivatives. Furthermore, the differentiation of vertebral body chondrocytes in Mesp2-null mice was spatially disordered and largely delayed, with an increased cell proliferation rate. The quantitative three-dimensional immunofluorescence image analyses of phospho-Smad2 and -Smad1/5/8 revealed that these chondrogenic phenotypes were associated with spatially disordered inputs of TGF-β and BMP signaling in the Mesp2-null chondrocytes, and also demonstrated an amorphous arrangement of cells with distinct properties. Furthermore, a significant delay in ossification in Mesp2-null vertebrae was observed by peripheral quantitative computed tomography. The current observations of the spatiotemporal disorder of vertebral organogenesis in the Mesp2-null mice provide further insight into the pathogenesis of SCDO and STDO, and the physiological development of the axial skeleton.

[Burn scars]

Burns often result in extensive scars which can change the body aesthetically and/ or functionally. Rapid scarring is a sign of a good prognosis. Preventative actions such as hydration, compression, massage, posture and splints help to prevent or contain the negative evolution of pathological scars.

Pigmentary hypertrichosis and non-autoimmune insulin-dependent diabetes mellitus (PHID) syndrome is associated with severe chronic inflammation and cardiomyopathy, and represents a new monogenic autoinflammatory syndrome

Mutations in SLC29A3 lead to pigmentary hypertrichosis and non-autoimmune insulin-dependent diabetes mellitus (PHID) and H syndromes, familial Rosai-Dorfman disease, and histiocytosis-lymphadenopathy plus syndrome. We report a new association of PHID syndrome with severe systemic inflammation, scleroderma-like changes, and cardiomyopathy. A 12-year-old girl with PHID syndrome presented with shortness of breath, hepatosplenomegaly, and raised erythrocyte sedimentation rate and C-reactive protein. An echocardiogram showed biventricular myocardial hypertrophy, and cardiac magnetic resonance imaging showed circumferential late gadolinium enhancement of the myocardium. No systemic amyloid deposits were observed on a whole-body serum amyloid P scintigraphy scan. Abdominal ultrasound revealed intra-abdominal fat surrounding the solid organs, suggesting a possibility of evolving lipodystrophy with visceral adiposity. PHID syndrome is a novel monogenic autoinflammatory syndrome (AIS) associated with severe elevation of serum amyloid. Lipodystrophy, cutaneous sclerodermatous changes, and cardiomyopathy were also present in this case. In contrast to other AIS, blockade of interleukin-1 and tumor necrosis-α was ineffective.

[Open arthrolysis for elbow stiffness: a report of 17 cases]

OBJECTIVE

To investigate the treatment effect of open arthrolysis for elbow stiffness.

METHODS

From Aug. 2007 to Apr. 2012, 17 cases of elbow stiffness were treated with open arthrolysis,in which, 11 were post-traumatic stiffness and 6 elbow stiffness resulted from rheumatoid arthritis and osteoarthritis. The preoperative Mayo elbow score was 65.1±16.4. Posterior middle approach was applied for 15 cases, and primary lateral approach for 2 cases. The ulnar nerve release and antedisplacement were performed for 12 cases with series limited flexion. The mobile hinged fixator were applied for 2 cases of unstable elbow after debridement of series hero ossification.

RESULTS

With follow-up time for 6 to 41 months (average 13.1 months), all the patients acquired the follow-up and evaluation. According to Mayo elbow score of the last follow-up, the score was 87.5±16.7, and compared with the preoperation, the difference was significant: 9 cases were excellent, 6 good, 1 fair, and 1 poor, and the total excellent and good rate was 88.23%. The active range of motion (ROM) of flexion-extension was 110.6°±27.5°. However, 1 case developed chronic infection, and 1 ulnar nerve symptom.

CONCLUSION

In applying open arthrolysis to treat elbow stiffness, as long as we release completely and assure stable elbow and early postoperative motion, we can get satisfying results.

Resection of the flexor digitorum superficialis for trigger finger with proximal interphalangeal joint positional contracture

PURPOSE

Open release of the A1 pulley is a widely known procedure for the treatment of trigger finger. A subset of patients presents with both trigger finger and a positional contracture of the proximal interphalangeal (PIP) joint. These patients usually have a long history of trigger finger or have already undergone a surgical release of the annular pulley. This study is a retrospective review of the outcomes of resection of the flexor digitorum superficialis (FDS) for patients whose trigger finger was associated with a positional contracture of the PIP joint.

METHODS

Thirty-six patients (39 fingers) were treated by resection of the FDS after section of the A1 pulley. The mean age of the patients was 63 years (range, 45-90 y). Seven patients (19 %) had previously undergone an open release of the A1 pulley and had developed a positional contracture of the PIP joint 2 to 5 months afterward. We performed a retrospective review with a mean follow-up of 30 months (range, 12-60 mo). No patient was lost to follow-up. The active range of motion was recorded at the PIP joint before and after surgery.

RESULTS

The mean preoperative positional contracture of the PIP joint was 24° (range, 15°-30°). The mean postoperative positional contracture of the PIP joint was 4° (range, 0°-10°). The most commonly affected digit was the middle finger (26 fingers, 67%). In 28 fingers (72%), full extension was achieved following only the surgical procedure. The remaining 11 fingers (28%) had a postoperative residual positional contracture (range, 5°-10°). However, all fingers achieved a full range of motion after physical therapy and an injection of betamethasone. All of the resected tendons had histological damage.

CONCLUSIONS

This technique is a useful treatment for selected patients whose trigger finger is associated with a positional contracture.

Factors affecting functional outcome of surgical correction of claw hand in leprosy

The objective of this paper is to study the results and the factors that impact the results of claw hand surgery in leprosy. 110 patients who underwent claw hand correction between 2002 and 2006 were followed up and studied. Brand's criteria for objective assessment and a visual analog scale for subjective assessment were used. The factors studied were age, sex, clinical, duration of paralysis, long flexor tightness, degree of contracture and type of surgery. Objective assessment showed Excellent or Good results in 76.6%, Fair in 20% and Poor in 3.4%. Subjective assessment showed that 80.8% were fully satisfied or satisfied. Regression analysis showed that age, degree of contracture,duration of paralysis and long flexor contracture were seen as significant factors impacting results of claw hand correction.

[Upper limb free flap for repair of severe contracture of thumb web and one stage reconstruction of index finger abduction]

OBJECTIVE

To evaluate the effectiveness of the upper limb free flap for repair of severe contracture of thumb web, and one stage reconstruction of the index finger abduction.

METHODS

Between March 2007 and June 2011, 16 cases of severe contracture of thumb web and index finger abduction dysfunction were treated. There were 14 males and 2 females with an average age of 29 years (range, 16-42 years). All injuries were caused by machine crush. The time between injury and admission was 6-24 months (mean, 10 months). The angle of thumb web was 10-25 degrees (mean, 20 degrees), and the width of thumb web was 15-24 mm (mean, 22 mm). After scar relax of the thumb web, the defect size ranged from 6 cm x 4 cm to 8 cm x 6 cm; the upper limb free flap from 7 cm x 5 cm to 9 cm x 7 cm was used to repair the defect, index finger abduction was simultaneously reconstructed by extensor indicis proprius tendon transfer. The donor site was repaired with skin grafting.

RESULTS

All the flaps and skin graftings survived after operation and incisions healed by first intention. Fourteen patients were followed up 6-12 months (mean, 9 months). The flap appearance was satisfactory. The two-point discrimination was 6-9 mm (mean, 7 mm) after 6 months. The angle of thumb web was 85-90 degrees (mean, 88 degrees). The width of thumb web was 34-52 mm (mean, 40 mm). The abduction and opposing functions of thumb and abduction function of index finger were both recovered.

CONCLUSION

A combination of the upper limb free flap for severe contracture of thumb web and one stage reconstruction of the index finger abduction for index finger abduction dysfunction can achieve good results in function and appearance.

Transcriptional abnormalities of hamstring muscle contractures in children with cerebral palsy

Cerebral palsy (CP) is an upper motor neuron disease that results in a spectrum of movement disorders. Secondary to the neurological lesion, muscles from patients with CP are often spastic and form debilitating contractures that limit range of motion and joint function. With no genetic component, the pathology of skeletal muscle in CP is a response to aberrant complex neurological input in ways that are not fully understood. This study was designed to gain further understanding of the skeletal muscle response in CP using transcriptional profiling correlated with functional measures to broadly investigate muscle adaptations leading to mechanical deficits.Biopsies were obtained from both the gracilis and semitendinosus muscles from a cohort of patients with CP (n = 10) and typically developing patients (n = 10) undergoing surgery. Biopsies were obtained to define the unique expression profile of the contractures and passive mechanical testing was conducted to determine stiffness values in previously published work. Affymetrix HG-U133A 2.0 chips (n = 40) generated expression data, which was validated for selected transcripts using quantitative real-time PCR. Chips were clustered based on their expression and those from patients with CP clustered separately. Significant genes were determined conservatively based on the overlap of three summarization algorithms (n = 1,398). Significantly altered genes were analyzed for over-representation among gene ontologies and muscle specific networks.The majority of altered transcripts were related to increased extracellular matrix expression in CP and a decrease in metabolism and ubiquitin ligase activity. The increase in extracellular matrix products was correlated with mechanical measures demonstrating the importance in disability. These data lay a framework for further studies and development of novel therapies.

Early results of surgical intervention for elbow deformity in cerebral palsy based on degree of contracture

PURPOSE

Elbow flexion posture, caused by spasticity of the muscles on the anterior surface of the elbow, is the most common elbow deformity seen in patients with cerebral palsy. This study retrospectively evaluated early results of 2 surgical interventions for elbow flexion deformities based on degree of contracture. We hypothesized that by guiding surgical treatment to degree of preoperative contracture, elbow extension and flexion posture angle at ambulation could be improved while preserving maximum flexion.

METHODS

Eighty-six patients (90 elbows) were treated for elbow spasticity due to cerebral palsy. Seventy-one patients (74 elbows) were available for follow-up. Fifty-seven patients with fixed elbow contractures less than 45° were surgically treated with a partial elbow muscle lengthening, which included partial lengthening of the biceps and brachialis and proximal release of the brachioradialis. Fourteen patients (17 elbows) with fixed elbow contractures ≥ 45° had a more extensive full elbow release, with biceps z-lengthening, partial brachialis myotomy, and brachioradialis proximal release.

RESULTS

Age at surgery averaged 10 years (range, 3-20 y) for partial lengthening and 14 years (range, 5-20 y) for full elbow release. Follow-up averaged 22 months (range, 7-144 mo) for partial lengthening and 18 months (range, 6-51 mo) for full elbow release. Both groups achieved meaningful improvement in flexion posture angle at ambulation, active and passive extension, and total range of motion. Elbow flexion posture angle at ambulation improved by 57° and active extension increased 17° in the partial lengthening group, with a 4° loss of active flexion. In the full elbow release group, elbow flexion posture angle at ambulation improved 51° and active extension improved 38°, with a loss of 19° of active flexion.

CONCLUSIONS

Surgical treatment of spastic elbow flexion in cerebral palsy can improve deformity. We obtained excellent results by guiding the surgical intervention by the amount of preoperative elbow contracture.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Sagittal placement of the femoral component in total knee arthroplasty predicts knee flexion contracture at one-year follow-up

PURPOSE

Flexion contracture has been shown to impair function and reduce satisfaction following total knee arthroplasty (TKA). The aim of this study was to identify modifiable intra-operative variables that predict post-TKA knee extension.

METHODS

Data was collected prospectively on 95 patients undergoing total knee arthroplasty, including pre-operative assessment, intra-operative computer assisted surgery (CAS) measurements and functional outcome including range of motion at one year. Patients were divided into two groups: those with mild flexion contracture (> 5°) at the one-year follow-up and those achieving full extension.

RESULTS

The sagittal orientation of the distal femoral cut differed significantly between groups at the one-year follow-up (p = 0.014). Sagittal alignment of greater than 3.5° from the mechanical axis was shown to increase the relative risk of a mild flexion contracture at one-year follow-up by 2.9 times, independent of other variables.

CONCLUSION

Increasing the sagittal alignment of the distal femoral cut more than 3.5° from the mechanical axis is an independent risk factor for clinically detectable flexion contracture one year from index procedure.

COMPARISON OF THE SURGICAL OUTCOMES FOR TRIGGER FINGER AND TRIGGER THUMB: PRELIMINARY RESULTS

We reviewed 110 trigger digits, treated surgically, to compare the outcomes of trigger finger and trigger thumb in terms of peri-operative characteristics and complications. The patients with trigger thumb complained mainly of pain on motion, while those with trigger finger complained of triggering or limited range of motion. Trigger fingers had a significantly longer duration before surgery than did trigger thumbs. Trigger fingers took significantly longer for the symptoms to subside. In our series, 64% of trigger fingers had a flexion contracture of the PIP joint more than three weeks after surgery. Our results suggest that the peri-operative characteristics and outcomes differ between trigger finger and thumb, and that the surgical outcome for trigger finger was poorer than that for trigger thumb, partly due to flexion contracture of the PIP joint.

Intrinsic contractures of the hand

Contractures of the intrinsic muscles of the fingers disrupt the delicate and complex balance of intrinsic and extrinsic muscles, which allows the hand to be so versatile and functional. The loss of muscle function primarily affects the interphalangeal joints but also may affect etacarpophalangeal joints. The resulting clinical picture is often termed, intrinsic contracture or intrinsic-plus hand. Disruption of the balance between intrinsic and extrinsic muscles has many causes and may be secondary to changes within the intrinsic musculature or the tendon unit. This article reviews diagnosis, etiology, and treatment algorithms in the management of intrinsic contractures of the fingers.

CLINICAL RESULTS OF ARTHROLYSIS USING POSTERO-LATERAL APPROACH FOR POST-TRAUMATIC CONTRACTURE OF THE ELBOW JOINT

We evaluated clinical results and postoperative problems associated with arthrolysis for post-traumatic contracture of the elbow joint. Arthrolysis was carried out in 47 elbows in 46 patients. Age at the time of arthroplasty ranged from 12 to 64 years (average 33 years). The period from time of injury to arthrolysis ranged from six months to six years (average 16 months). It was notable that scarring of the anterior capsule was pronounced in cases of long-term contracture. No apparent differences were observed in causes or age at operation, but the duration of preoperative symptoms and period of postoperative external fixation tended to affect the outcome. We conclude that arthrolysis is indicated irrespective of preoperative range of motion (ROM) and age, and that the surgery should be carried out before degeneration of cartilage and muscle atrophy progress. It was considered that long-term postoperative observation is also necessary, because in some cases there was postoperative progression of joint deformities, while in others there was decreased muscle strength after surgery.

A review on static splinting therapy to prevent burn scar contracture: do clinical and experimental data warrant its clinical application?

BACKGROUND

Static splinting therapy is widely considered an essential part in burn rehabilitation to prevent scar contractures in the early phase of wound healing. However, scar contractures are still a common complication. In this article we review the information concerning the incidence of scar contracture, the effectiveness of static splinting therapy in preventing scar contractures, and specifically focus on the - possible - working mechanism of static-splinting, i.e. mechanical load, at the cellular and molecular level of the healing burn wound.

METHOD

A literature search was done including Pubmed, Cochrane library, CINAHL and PEDRO.

RESULTS

Incidence of scar contracture in patients with burns varied from 5% to 40%. No strong evidence for the effectiveness of static splinting therapy in preventing scar contracture was found, whereas in vitro and animal studies demonstrated that mechanical tension will stimulate the myofibroblast activity, resulting in the synthesis of new extracellular matrix and the maintenance of their contractile activity.

CONCLUSION

The effect of mechanical tension on the wound healing process suggests that static splinting therapy may counteract its own purpose. This review stresses the need for randomised controlled clinical trials to establish if static splinting to prevent contractures is a well-considered intervention or just wishful thinking.

Validity of gait parameters for hip flexor contracture in patients with cerebral palsy

BACKGROUND

Psoas contracture is known to cause abnormal hip motion in patients with cerebral palsy. The authors investigated the clinical relevance of hip kinematic and kinetic parameters, and 3D modeled psoas length in terms of discriminant validity, convergent validity, and responsiveness.

METHODS

Twenty-four patients with cerebral palsy (mean age 6.9 years) and 28 normal children (mean age 7.6 years) were included. Kinematic and kinetic data were obtained by three dimensional gait analysis, and psoas lengths were determined using a musculoskeletal modeling technique. Validity of the hip parameters were evaluated.

RESULTS

In discriminant validity, maximum psoas length (effect size r = 0.740), maximum pelvic tilt (0.710), maximum hip flexion in late swing (0.728), maximum hip extension in stance (0.743), and hip flexor index (0.792) showed favorable discriminant ability between the normal controls and the patients. In convergent validity, maximum psoas length was not significantly correlated with maximum hip extension in stance in control group whereas it was correlated with maximum hip extension in stance (r = -0.933, p < 0.001) in the patients group. In responsiveness, maximum pelvic tilt (p = 0.008), maximum hip extension in stance (p = 0.001), maximum psoas length (p < 0.001), and hip flexor index (p < 0.001) showed significant improvement post-operatively.

CONCLUSIONS

Maximum pelvic tilt, maximum psoas length, hip flexor index, and maximum hip extension in stance were found to be clinically relevant parameters in evaluating hip flexor contracture.

Post-traumatic combined flexion of the thumb, index and middle finger after intrinsic muscles reconstruction of the hand: a case report

We report a case in which simultaneous flexion of the thumb, index and middle finger occurred 6 months after the surgical reconstruction of the adductor (AM) and first dorsal interosseous (IO) muscles. An anomalous connection in the form of tendon slip associated to fibrous adhesions between the flexor pollicis longus (FPL) tendon, flexor digitorum profundus indicis (FDPI) and middle finger (FDPM) tendons were found. Either ultrasound (US) examination or magnetic resonance imaging (MRI) were unable to detect the site of adhesion. Excision of the slip and radical tenosynoviectomy led to early functional recovery.

Hinged cast brace for persistent flexion contracture following total knee replacement

The reported incidence of persistent knee flexion contracture following total knee arthroplasty (TKA) has varied from 1-15 percent Various treatment modalities have been described in attempts to manage this often difficult problem. This paper describes a novel method of treatment by using a hinged cast brace (previously reported for treatment of femur fractures and knee contractures secondary to hemophilia and cerebral palsy) for use in patients with symptomatic knee flexion contractures. Application of this cast brace with frequent adjustment (every three to four days, initially) toward full extension can often improve knee extension, after physical therapy and other modalities such as extension-assist braces have failed. Care must be taken in the application and use of this device which utilizes frequent manipulations to reduce and maintain the knee flexion angle. We report two clinical cases in which this protocol was effectively used in decreasing symptomatic knee flexion contractures.

Contractures of the upper extremities in spinal muscular atrophy type II. Descriptive clinical study with retrospective data collection

BACKGROUND

The most significant orthopaedic problem for patients with the intermediate form of spinal muscular atrophy, SMA type II, is the appearance of contractures in addition to progressive scoliosis and pelvic obliquity with increasing loss of sitting stability. This study deals with restrictions of the passive range of motion and the development of contractures in the joints of the upper extremities in these patients.

MATERIAL AND METHODS

We followed up 143 patients, 74 female and 69 male, with SMA type II for an average of 5.3 years (± 4.0, 0.2 - 18.7). Their average age at the first examination was 8.4 years (± 6.6, 0.1 - 34.1) and at the last examination 12.3 years (± 6.5, 0.7 - 37.1). The passive range of joint motion was determined using a goniometer. According to Johnson et al. (1992), we calculated the relative contracture index (CI).

RESULTS

The loss of range of motion and the contractures of the joints of the upper extremities (shoulder, elbow and wrist) increased progressively with age. The most marked restriction of motion was in the elbow joint with severe flexion contractures in some cases.

CONCLUSION

The findings of this study give us more information about the development of contractures of the upper extremities and aim to help to improve the quality of orthopaedic care of patients with SMA type II.