[Treatment of contractures of the lower extremity joints in patients with infantile cerebral palsy against the background of prolonged epidural blockade]

The authors describe specific effects of prolonged epidural blockade in treatment of contractures of the lower extremity joints in children with cerebral palsy. The method was used in 5 patients aged from 11 to 16 years. The prolonged epidural blockade during 4-5 weeks allowed adequate motor rehabilitation and conditions for learning to walk.

Does tendon lengthening surgery affect muscle tone in children with cerebral palsy?

The objective of this study was to determine if surgical lengthening of the hamstrings and gastrocnemius/Achilles complex affects muscle tone in patients with cerebral palsy. The question was if the dynamic component of muscle length changes after orthopedic surgery. A retrospective study was performed on ambulatory children with cerebral palsy who underwent either hamstring lengthening or gastrocnemius/Achilles tendon lengthening. A total of 135 consecutive patients with an average age of 13 years were included in the study. A single random side was selected for children with bilateral surgery and the affected limb was analyzed for those undergoing unilateral surgery. The popliteal angle measurement was performed with a quick and slow stretch, as well as the ankle dorsiflexion, and measurements were made using a goniometer. The difference (delta ml) between initial grab with fast stretch and end of range (EOR) with slow stretch was used as a measure of spasticity. The Bohannon modification of the Ashworth score was also assessed. Postoperatively, 18 degrees popliteal angle improvement in end-of-range and 32 degrees improvement in quick stretch in the hamstrings group were noted, with change in slow stretch, quick stretch and delta ml (comparison between quick and slow stretch) being significant at p < .0001. In the triceps surae group, 14 degrees ankle dorsiflexion improvement in end-of-range, and 18 degrees improvement in quick stretch were noted postoperatively, with change in slow stretch, quick stretch and delta ml at p < .0001, p < .0001, and p < .0180 respectively. Ashworth scale was reduced by at least one grade in 89% of subjects in the hamstring group and 78% of subjects in the triceps surae group of the children with preoperative Ashworth 3 and above.

Alternative splinting approach for proximal interphalangeal joint flexion contractures: no-profile static-progressive splinting and cylinder splint combo

Proximal interphalangeal joint (PIPj) flexion contractures can be challenging contractures to resolve. Through the years, numerous splints have been designed to treat such contractures. However, despite the abundance of available splints, therapists are always modifying splinting designs and incorporating new concepts into these designs to treat this challenging problem. These authors are presenting another method of modifying splinting concepts to treat PIPj flexion contractures.

An alternative approach in the treatment of thumb web contracture skin defects: lateral tarsal artery flap

BACKGROUND

Thumb web contracture is a common complication after hand injury, and can markedly affect whole hand function. Therefore, surgery involving thumb web reconstruction is often necessary to restore normal function of the involved hand. In this study, we present the application of the lateral tarsal artery (LTA) flap in first web reconstruction.

METHODS

From November 1, 2005 to October 31, 2007, seven patients with severe post trauma or burn contractures around the first web space were treated with a LTA flap. All the patients were followed up.

RESULTS

All flaps survived, with an average size of 6.7 cm x 4.8 cm. There were no complications or recurrent contractures during follow-up. All patients were satisfied with the esthetic appearance and functional outcome of the reconstruction.

CONCLUSION

The LTA flap could be an excellent option for covering various defects in the thumb web space, serving as an excellent alternative for the thumb web space reconstruction.

Relation between spasticity, weakness and contracture of the elbow flexors and upper limb activity after stroke: An observational study

PURPOSE

Understanding the relationship between the motor impairments and their impact on physical activity will allow rehabilitation after stroke to be based on scientific principles. The aims of this study were to determine: (i) the relative contribution of weakness and spasticity to contracture, and (ii) the relative contribution of all three impairments to limitations in physical activity during the first 12 months after stroke.

METHOD

This longitudinal observational study charted the evolution of weakness (loss of maximal force), spasticity (stretch-evoked EMG) and contracture (loss of joint range) of the elbow flexors and limitations in upper limb activity (Motor Assessment Scale) for a year after stroke in 27 subjects who had suffered a first stroke. Spasticity was measured as abnormal reflex activity, weakness was measured as loss of maximum isometric torque, contracture was measured as the difference in range of motion between the affected and intact side, and limitations in physical activity were measured on a clinical scale.

RESULTS

The major independent contributors to contracture were spasticity for the first four months after stroke (p = 0.0001 - 0.10) and weakness thereafter (p = 0.01 - 0.05). However, the major and only independent contributor to limitations in physical activity throughout the year was weakness (p = 0.0001 - 0.05).

CONCLUSIONS

For the first time, from a longitudinal study, the findings show that spasticity can cause contracture after stroke, consistent with the prevailing clinical view. However, weakness is the main contributor to activity limitations.

Contractures and involuntary muscle overactivity in severe brain injury

PRIMARY OBJECTIVE

The aim of the present study was to evaluate the association of contractures with an increase or reduction of non-spastic muscle overactivity due to severe cerebral damage.

METHODS AND PROCEDURES

Forty-five patients with tetraparesis after severe cerebral damage were investigated. Three groups were defined based on the presence of spasticity (revealed as resistance to passive stretch (= hypertonia)), and the presence of contracture of the relevant knee joint: Group(s) (17 patients with hypertonia without contracture), Group(s+c) (20 patients with hypertonia and contracture), and Group(c) (eight patients without hypertonia and with contracture). In all groups spontaneous involuntary muscle activity was assessed continuously over a 12-hour period through isometric measurement of knee joint flexion torque. A mathematical algorithm differentiated an hourly muscle activity spectrum (PI(h)). The frequency of peaks (peaks(h)) from the activity spectrum was determined.

MAIN OUTCOMES AND RESULTS

We revealed that Group(s) had higher PI(h) and more frequent peaks(h) compared with Group(s+c) and Group(c) (p<0.05). Group(c) had comparable PI(h) and peaks(h) compared with Group(s+c) (p>0.05).

CONCLUSION

The presence of contractures was associated with lower involuntary muscle overactivity in terms of lower PI(h) and less frequent peaks(h), indicating that contractures may be associated with reduced non-spastic positive features of the upper motor neurone syndrome in patients with severe brain damage.

[Clinic peculiarities of secondary flexion contractur formation in the proximal interphalangeal joint of the triphalanger fingers in conditions of posttraumatic chronic ischemia]

Occurrence of the proximal interphalangeal (PIP) joints contracture is a characteristic consequence of traumas of a forearm and a hand, complicated by the phenomena of a chronic ischemia. Their formation leads to occurrence of considerable functional deficiency of a hand, especially at involving in process of several fingers, and treatment is a complicated problem. Secondary contractures of PIP joints at a chronic ischemia of a hand and fingers differ high severity level, firmness, are characterized by fast formation and progressing. Elimination of the primary factor of blocking of a kinematic chain at a chronic ischemia of a hand and fingers does not render influence on reduction secondary contractures of PIP joints and leads to necessity of performance of additional surgery.

Joint capsule mast cells and neuropeptides are increased within four weeks of injury and remain elevated in chronic stages of posttraumatic contractures

The purpose of this article was to determine mast cell and neuropeptide nerve fiber numbers in joint capsules in posttraumatic contractures, as elevated numbers have been implicated in other fibrotic and contracture conditions. Twelve skeletally mature rabbits had intraarticular cortical windows removed from the medial and lateral femoral condyles and the knee joint immobilized. The contralateral unoperated limb served as a control. Equal numbers of rabbits were sacrificed 4 weeks after surgery or 40 weeks after the first surgery that included 32 weeks of remobilization. Six patients with chronic posttraumatic elbow joint contractures and six age-matched organ donor controls free of elbow contractures were also studied. Joint capsule myofibroblast, mast cell, and neuropeptide containing nerve fiber numbers were assessed with immunohistochemistry. The numbers of myofibroblasts, mast cells, and neuropeptide containing nerve fibers expressed as a percentage of total cells were significantly greater in the contracture capsules when compared to the control capsules at all time points (p < 0.0001). The range of percentages for the three components in the contracture capsules versus the controls were 41-48% versus 9-10%, 44-50% versus 11-13%, and 45-50% versus 10-12% for the acute and chronic stages of the rabbit model and the chronic stages in the human elbows, respectively. These data support the hypothesis that a myofibroblast-mast cell-neuropeptide fibrosis axis may underlie some of the pathologic changes in the joint capsule in posttraumatic contractures. Approaches designed to manipulate this axis, such as preventing degranulation of mast cells, warrant further investigation.

Ehlers-Danlos syndrome type VIB with characteristic facies, decreased curvatures of the spinal column, and joint contractures in two unrelated girls

Two unrelated girls, aged 11 and 14 years, with clinical manifestations of Ehlers-Danlos syndrome (EDS) type VIB, characteristic facies, skeletal abnormalities, and other features are described. They had Marfanoid habitus with pectus excavatum; fragile, hyperextensible, and readily bruisable skin with widened, atrophic scars; recurrent hematomas; generalized joint laxity; hypotonia; scoliosis; and mild delay of gross motor development. Lysyl hydroxylase deficiency was ruled out in Patient 1. Parental consanguinity was present in Patient 2. They both had, in early childhood, down-slanting palpebral fissures, drooping lower eyelids, short nose, small mouth, and long philtrum. Facial features that persisted included thick eyebrows, hypertelorism, strabismus, blue sclerae, low-set, and slanted ears, hypoplastic columella, high-arched palate, and thin upper lip. They had tubular stenosis of the phalanges, metacarpals, and metatarsals; decreased physiological curvatures of the spinal column with tall vertebrae; and joint contractures including talipes equinovarus and progressive talipes valgus. Their hearing of high-pitched sounds was impaired. They had constipation and recurrent cystitis with an enlarged bladder. In view of these findings, we propose that these two girls represent a clinically recognizable subgroup of EDS type VIB.

A novel mutation in the central rod domain of lamin A/C producing a phenotype resembling the Emery-Dreifuss muscular dystrophy phenotype

Lamins are the principal components of the nuclear lamina, a network constituting the major structural framework of the nuclear envelope. Alterations in lamin A/C have been associated with a heterogeneous series of human disorders known as laminopathies. We report the finding of a novel deletion in the central rod domain of lamin A/C exon 3 gene in four members of the same family. This genetic alteration was likely responsible for the relatively homogeneous clinical phenotype observed in our three patients, represented by a prominent cardiac conduction-system disease necessitating permanent pacemaker implantation, and limited skeletal involvement manifested by spinal rigidity and contractures. The findings from these cases further expand the clinical spectrum associated with mutations in the LMNA gene.

Open elbow arthrolysis for post-traumatic elbow contracture

BACKGROUND

Post-traumatic contracture is a common complication after elbow trauma. If conservative therapy fails to restore adequate elbow motion, arthrolysis is indicated. The purposes of this study were to evaluate the clinical outcome of open arthrolysis for post-traumatic elbow contracture and to determine factors influencing the outcome.

METHODS

Twenty-seven patients with post-traumatic elbow contracture were followed-up after open arthrolysis for at least 12 months. Before surgery, the mean limitation in extension was 30 and the mean maximum flexion was 83 degrees. A posterior surgical approach was used in 18 patients, and a lateral approach was employed in nine patients. Using the posterior approach, the fibrotic posterior capsule was excised and the ulnar collateral ligament was split. Both the anterior and posterior capsules were released with a lateral approach.

RESULTS

The mean flexion increased from 83 degrees to 121 degrees, but the mean extension improved little from -30 degrees to -26 degrees. The mean flexion-extension arc increased from 53 degrees to 95 degrees. According to the elbow evaluation score by the Japanese Orthopaedic Association, both pain and function scales improved significantly. By Hertel's subjective evaluation, the results were good in 13 patients, fair in ten patients, and poor in four patients. Twenty-three patients (85 percent) were satisfied with the results, but four were not satisfied because of residual contracture. These poor results were related to severe soft tissue trauma, residual displacement of intra-articular fragments, and recurrence of heterotopic bone formation.

CONCLUSIONS

Tendon lengthening of stiff triceps, accurate reduction of intra-articular fragments, and sharp epiperiosteal resection around the heterotopic bones are essential procedures of open arthrolysis to restore adequate motion in post-traumatic elbow contracture.

The exoshift under anesthesia correlates with probable changes in medial rectus innervation after surgery for infantile esotropia

PURPOSE

To study the outward deviation of the eyes (exoshift) under anesthesia, in a variety of clinical settings in order to improve our understanding of how medial rectus recessions change alignment and innervation.

METHODS

Pre-operative and intraoperative eye deviations were measured before surgery and under Stage 3 of general anesthesia using a modified Krimsky test in 5 groups: 1) Unoperated infantile esotropia (N=60); 2) Undercorrected infantile esotropia (N=27); 3) Corrected infantile esotropia with subsequent vertical deviations (N=17); 4) Superior oblique palsies without horizontal deviations (N=21); and 5) Late consecutive exotropia (N=16).

RESULTS

Group 2 averaged half the esotropic deviation of Group 1 (19.8 +/-7.4 ET vs. 42.1 +/-18.3 ET), but had a nearly identical exoshift (41.9 +/-13.2 vs. 41.8 +/-13.6, p=0.96). Group 4 (orthotropic) and Group 5 (exotropic) demonstrated smaller and nearly identical exoshifts (26.0 +/-8.3 vs.24.0 +/-9.3, p=0.50). Group 3 had significantly less exotropia (30.1 +/-6.0) than Group 1 and 2 (p=0.002 for both), but significantly more exoshift than Group 4 (p=0.04) or Group 5 (p=0.067).

CONCLUSION

Contracture of the lateral rectus reduced the deviations after undercorrecting surgery, but the exoshift remained unchanged. Medial rectus recession by itself has no effect on normal level seen in consecutive exotropia. These data combined with a reasonable set of assumptions regarding the state of contracture (expansure) of the horizontal rectus in a variety of pre- and post-operative settings lead to the conclusion that setting the eyes straight with a successful bilateral medical rectus recession reduces the pre-operative hyperinnervation of medial rectus almost to normal, with a small amount of residual hyperinnervation remaining to overcome the increased contacture of the lateral rectus which occurs due to increased exotropia during sleep after a bilateral medial rectus recession. When this small residual hyperinnervation decreases to normal, consecutive exotropia develops, owing to continued increased contracture of the lateral recti.

Rigid spine syndrome: vacuolar variant multimodal evoked potentials

BACKGROUND

Overt or covert central nervous system (CNS) abnormalities have been reported in various primary muscle diseases, including congenital muscular dystrophies.

PURPOSE

To ascertain by neurophysiologic techniques evidence of CNS dysfunction in a relatively large, homogeneous group of patients with the "vacuolar variant" of the rigid spine syndrome (RSS).

METHODS

Standard evoked potential (EP) techniques were used to study the visual, auditory and somatosensory pathways in patients with RSS.

RESULTS

Abnormal values were recorded in 78% (7/9) of patients, specifically of visual pathways (2/9), brainstem auditory pathways (2/9), and somatosensory pathways (5/9), and the retina (1/9). Abnormal findings were not correlated with clinical measures of patient age, disease duration nor degree of weakness.

CONCLUSION

Electrophysiological studies showed that the CNS is not primarily involved in any disease process that underlies this congenital myopathy. There were reasonable other explanations for most abnormal measurements.

Inhibition of rho-kinase impairs fibroblast stress fiber formation, confluence, and contractility in vitro

Rho kinase is an enzyme that has been implicated in pathological wound healing. In our study, we aimed to characterize the dosages of Y-27632 (a competitive inhibitor of rho kinase) at which fibroblast stress fiber formation is inhibited, to determine the effect of Y-27632 on fibroblast confluence, and to determine the effect of varying concentrations of Y-27632 on fibroblast-mediated gel contraction. First, 3T3 fibroblasts were exposed to various concentrations of Y-27632, and stress fiber dissolution was assessed with immunofluorescence. Next, 10 microM Y-27632 was applied to 3T3 fibroblast monolayer cultures immediately after plating and at 8 hours after plating to determine the effect on fibroblast confluence. Finally, a three-dimensional model was used to assess the effect of Y-27632 on gel contraction. Increasing doses of Y-27632 resulted in a dose-dependent increase in stress fiber dissolution as well as a dose-dependent inhibition of gel contraction. Median number of days to confluence were 3, 5, and 6 after no, immediate, and delayed incubation with Y-27632, respectively (P < .05). Our results further characterize the dosages at which Y-27632 may be most effective in the modulation of wound contraction in burn patients. In addition, our confluence study suggests that patients need not necessarily be pretreated with Y-27632.

Reliability of popliteal angle measurement: a study in cerebral palsy patients and healthy controls

The popliteal angle is a widely used clinical measure for hamstring contracture in cerebral palsy (CP) patients and in healthy individuals. The reliability of popliteal angle measurement is being questioned. The aim of this study is to determine the reliability of popliteal angle measurement by means of visual and goniometric assessment.

METHODS

Three different observers measured the popliteal angle in 15 CP patients and 15 healthy volunteers. In each subject, popliteal angles were visually estimated and measured with a blinded goniometer twice by all observers with approximately 1 hour between measurement sessions.

RESULTS

All intraclass correlation coefficients (ICCs) were lower in the CP group compared with healthy controls. The ICC for intraobserver differences was higher than 0.75 for both groups. The ICC for interobserver reliability of visual estimates and goniometric measurements was low for both groups. Intermethod ICC was higher than 0.75 for both groups.

CONCLUSIONS

Measurements in the CP group seemed to be less reliable than measurements in the control group. Intraobserver reliability is reasonable for both groups, but lower in CP patients than in controls. Interobserver reliability of both visual estimates and goniometrical measurements is poor. No significant differences in reliability have been found between visual estimation and goniometric measurement. Because of poor interobserver reliability of popliteal angle measurement, this should not be the only variable in clinical decision making in CP patients.

Comparison of elbow contracture release in elbows with and without heterotopic ossification restricting motion

We compared 16 patients with post-traumatic heterotopic ossification (HO) restricting elbow motion (but not complete bony ankylosis) after elbow trauma with 21 patients with capsular contracture alone to test the hypothesis that HO is associated with diminished motion after release. Patients with burns or head injury were excluded. The preoperative flexion arc averaged 59 degrees in the HO cohort and 52 degrees in the capsular contracture cohort. The mean flexion arc after the index surgery improved by 54 degrees to a mean arc of 113 degrees in the HO cohort and by 35 degrees to a mean of 87 degrees in the capsular contracture cohort (P = .02). After all subsequent procedures (including procedures to address residual stiffness in 1 patient in the HO cohort and 4 patients in the capsular contracture cohort), the flexion arc averaged 116 degrees in the HO cohort and 98 degrees in the capsular contracture cohort (P = .19). Open release of post-traumatic elbow stiffness is more effective when HO hindering motion is removed than when there is capsular contracture alone.

Assessment and treatment of glenohumeral joint deformities in children suffering from upper obstetric brachial plexus palsy

We present our approach to gleno-humeral joint deformities as sequelae from severe upper obstetric brachial plexus palsy. In 50 consecutive children with severe medial rotation contracture of the shoulder after obstetric brachial plexus palsy, we used magnetic resonance imaging to evaluate joint incongruence and dysplasia; showing frequently various deformities of the glenoid, the humeral head and pathologic changes in their relationship. The most severe deformity is true glenohumeral dysplasia. These diagnostic findings might influence our choice and technical details within surgical procedures. We actually evaluate image processing tools (segmentation software) for a better understanding of changes in anatomical structures responsible for this multifactorial joint deformity, limiting lateral and/or medial rotation of the glenohumeral joint in children with obstetric brachial plexus palsy.

[The effect of children's gluteal muscle contracture on skeleton development]

OBJECTIVE

To explore the effect of children's gluteal muscle contracture (GMC) on skeleton development.

METHODS

The pelvic plain films of 368 GMC cases confirmed by operation from May 1995 to June 2005 and those of 200 individuals as control were analyzed for this research project. The pelvic CT scans were performed in 30 GMC cases and 25 controls. The data of both groups were used to comparison, analysis and statistics treatment in pelvic plain X-ray film, hip joint, acetabular index, neck shaft angle, centre-edge (CE) angle, the form of pelvic obturator foramen, the existence or nonexistence of the iliac hyperdense line.

RESULTS

There were 68 cases with pelvis obliquity in the case group but no one in the control group. The iliac hyperdense lines at the side of sacroiliac joints were found on the pelvic plain films of 321 of 368 cases with GMC and 5 of 200 controls. In 368 cases with GMC, the iliac hyperdense lines were detected in 306 of 314 patients beyond 7-year-old, and 313 of 336 appeared mostly the contracture of gluteus maximus muscle, which showed to be significant in statistics. In GMC group, the oblique plane became steeper and almost oriented posteroanteriorly, while in control group,the pelvic CT showed that the outer codex of posterior ilium at the level of sacroiliac joint appeared as an oblique plane, oriented from posteromedial to anterolateral side. The data were processed with statistics software, found that compared with the control group, the results of pre-operation group's examines such as CE angle, neck shaft angle, longitudinal diameter, cross diameter, and the iliac hyperdense line had significant differences (P < 0.01), the results of post-operation group's those examines showed no significant differences (P > 0.01), and the acetabular index appeared no significant differences (P > 0.01).

CONCLUSION

The children's gluteal muscle contracture has the significant effect on skeleton development, which could lead to pelvis obliquity, coxa valga, leg length pseudoinequality, CE angle increasing, etc. The iliac hyperdense line on the pelvic plain film is probably a characteristic change of GMC.

Use of an in vitro model of tissue-engineered skin to investigate the mechanism of skin graft contraction

Skin graft contraction leading to loss of joint mobility and cosmetic deformity remains a major clinical problem. In this study we used a tissue-engineered model of human skin, based on sterilized human adult dermis seeded with keratinocytes and fibroblasts, which contracts by up to 60% over 28 days in vitro, as a model to investigate the mechanism of skin contraction. Pharmacologic agents modifying collagen synthesis, degradation, and cross-linking were examined for their effect on contraction. Collagen synthesis and degradation were determined using immunoassay techniques. The results show that skin contraction was not dependent on inhibition of collagen synthesis or stimulation of collagen degradation, but was related to collagen remodelling. Thus, reducing dermal pliability with glutaraldehyde inhibited the ability of cells to contract the dermis. So did inhibition of matrix metalloproteinases and inhibition of lysyl oxidase-mediated collagen cross-linking, but not transglutaminase-mediated cross-linking. In summary, this in vitro model of human skin has allowed us to identify specific cross-linking pathways as possible pharmacologic targets for prevention of graft contracture in vivo.

A computer-controlled contracture correction device with low-load and continuous torque: an animal experiment and prototype design for clinical use

The purpose of this study was to clarify the relationship between mechanical stress and tissue response of the contracted knee joint in rats and to propose a new design of contracture correction device for clinical use. Wistar rats were operated on to immobilize their knee joints with a procedure causing periarticular bleeding and were kept in flexed position for 40 days. At day 40, the immobilizing wire was removed, and after day 43, the contracted knee joint had been treated with tunable corrective devices secured by an external fixation method to the rear limb. These devices consisted of four types of motor-driving system which provided several different low-load and continuous stretch torques. Measuring the angle of maximum knee extension, its effectiveness was assessed comparing with a lower load and control group of natural recovery course. The device also had a cyclic joint movement within the acquired range of motion and an oval cam mechanism producing a small distraction force to the joint along its long axis. The results showed that an appropriate range of low-load continuous torque was more effective to correct joint contracture. On the basis of the animal experiment, a new computer-controlled, gas-driven contracture correction device was developed for clinical trial. It was concluded that mechanical application in a condition with low and continuous torque is a useful treatment for fixed joint contracture.