Surgical Management of Spasticity of the Forearm and Wrist

Surgical Treatment in Post-Stroke Spastic Hands: A Systematic Review

Background: For more than two decades, the surgical treatment of post-stroke spastic hands has been displaced by botulinum toxin therapy and is currently underutilized. Objectives: This article aimed to assess the potential of surgery for treating a post-stroke spastic upper extremity through a systematic review of the literature on surgical approaches that are adopted in different profiles of patients and on their outcomes and complications. Methods: Medline PubMed, Web of Science, SCOPUS, and Cochrane Library databases were searched for observational and experimental studies published in English up to November 2022. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluations (GRADE) system. Results: The search retrieved 501 abstracts, and 22 articles were finally selected. The GRADE-assessed quality of evidence was low or very low. The results of the reviewed studies suggest that surgery is a useful, safe, and enduring treatment for post-stroke spastic upper extremities, although most studied patients were candidates for hygienic improvements alone. Patients usually require an individualized combination of techniques. Over the past ten years, interest has grown in procedures that act on the peripheral nerve. Conclusions: Despite the lack of comparative studies on the effectiveness, safety, and cost of the treatments, botulinum toxin has displaced surgery for these patients. Studies to date have found surgery to be an effective and safe approach, but their weak design yields only poor-quality evidence, and clinical trials are warranted to compare these treatment options.

Validating the measurement of passive Musculo-articular wrist stiffness without intentional or reactive contraction using axillary plexus block

BACKGROUND

Passive stiffness describes how easily a joint may move passively. To accurately measure wrist stiffness, an electro-oscillation device was developed. The objectives were to 1) ensuring that the measurement are free from intentional or reflex contraction, 2) analyzing how forearm anatomy affects the passive stiffness of the wrist and 3) determining the clinical practical relevance of the device.

METHODS

In this prospective study, the device generated low amplitude sinusoidal motions in flexion and extension on the wrist to quantify elastic and viscous passive stiffness in voluntary orthopaedic patients. The first series of measurements was carried out in the state of voluntary relaxation, the second series of measurements was carried out after an axillary plexus anesthetic block. A matched group of healthy subjects were use for control.

FINDINGS

The Electromechanical Oscillation methods effectively enable the measurement of passive joint stiffness since the stiffness values obtained show no statistically significant difference pre-post the anesthesia. The stiffness values are comparable to those of healthy subjects. The effect of forearm passive structure, estimated by the perimeter of the forearm, influences the passive stiffness of the wrist, mainly the viscous component.

INTERPRETATION

The use of sinusoidal oscillation was well accepted by the participants, demonstrating its usefulness and applicability in a clinical setting. This work serves as a foundation for future investigations of orthopaedic and/or neurological pathological conditions characterized by abnormal passive joint stiffness of the wrist. It paves the way for its use as a diagnostic, prognostic, and monitoring tool in these pathologies.

Effect of Proximal Row Carpectomy and Wrist Arthrodesis on the Resting Length of Extrinsic Digit Flexor Tendons: A Cadaveric Study

Background  Spastic joint contractures remain a complex and challenging condition. For patients with upper extremity spastic dysfunction, improving the muscle balance is essential to maximize their hand function. Multiple procedures, including proximal row carpectomy (PRC) and wrist arthrodesis (WA), are considered among the different surgical alternatives. However, the biomechanical consequences of these two procedures have not been well described in current literature. Hence, the objective of our study is to assess the change in the extrinsic digit flexor tendon resting length after proximal row carpectomy and wrist arthrodesis. Methods  Six fresh-frozen cadaver upper extremities (four females and two males) with no obvious deformity underwent dissection, PRC, and WA. All the flexor digitorum profundus (FDP), flexor digitorum superficialis (FDS), and flexor pollicis longus (FPL) tendons were marked proximally 1-cm distal to their respective myotendinous junction and cut distally at the marked point. The overlapping segment of each distal flexor tendon from its proximal mark was considered the amount of flexor tendon resting length change after PRC and WA. A descriptive evaluation was performed to assess the increment in tendon resting length. Additionally, a regression analysis was performed to evaluate the relation between the tendon resting length and the proximal carpal row height. Results  Following PRC and WA, the mean digit flexor tendon resting length increment achieved across all tendons was 1.88 cm (standard deviation [SD] = 0.45; range: 1.00-3.00 cm). A weak direct relationship ( R  = 0.0334) between the increment in tendon resting length and proximal carpal row height was initially suggested, although no statistical significance was demonstrated ( p  = 0.811). Conclusion  This study provides an anatomic description of the increased extrinsic digit flexor tendon resting length after PRC and WA in cadaveric specimens. Findings provide a useful framework to estimate the amount of extrinsic digit flexor resting length increment achieved after wrist fusion and the proximal carpal row removal.

A pilot study on lengthening potentials and biomechanical effects of double and triple hemisection on tendon with slide lengthening

The current study explored the slide-lengthening potentials of double and triple hemisections and the biomechanical effects of different inter-hemisection distances. Forty-eight porcine flexor digitorum profundus tendons were divided into double- and triple-hemisection groups (Groups A and B) and a control group (Group C). Group A was divided into Group A1 (distance between hemisections were the same as Group B) and Group A2 (distance between hemisections corresponded to the greatest distance between hemisections in Group B). Biomechanical evaluation, motion analysis, and finite element analysis (FEA) were performed. Failure load of intact tendon was significantly highest among groups. When the distance was 4 cm, the failure load of Group A increased significantly. When the distance between the hemisections was 0.5 or 1 cm, the failure load of Group B was significantly lower than Group A. Tendon elongation and failure load of Group B were significantly lower than those in Group A when the greatest distance between hemisections was the same. Consequently, Double hemisections had a similar lengthening ability to that of triple hemisections with the same distance, but better when the distances between extreme hemisections matched. However, the driving force for the initiation of lengthening may be greater.

Barriers to Upper Extremity Reconstruction for Patients With Cerebral Palsy

BACKGROUND

Reconstructive surgery for upper extremity manifestations of cerebral palsy (CP) has been demonstrated to be safe and effective, yet many potential candidates are never evaluated for surgery. The purpose of this study was to determine barriers to upper extremity reconstruction for patients with CP in a cohort of upper extremity surgeons and nonsurgeons.

METHODS

We sent a questionnaire to 4167 surgeons and nonsurgeon physicians, aggregated responses, and analyzed for differences in perceptions regarding surgical efficacy, patient candidacy for surgery, compliance with rehabilitation, remuneration, complexity of care, and physician comfort providing care.

RESULTS

Surgeons and nonsurgeons did not agree on the literature support of surgical efficacy (73% vs 35% agree or strongly agree, respectively). Both surgeons and nonsurgeons felt that many potential candidates exist, yet there was variability in their confidence in identifying them. Most surgeons (59%) and nonsurgeons (61%) felt comfortable performing surgery and directing the associated rehabilitation, respectively. Neither group reported that patient compliance, access to rehabilitation services, and available financial resources were a major barrier, but surgeons were more likely than nonsurgeons to feel that remuneration for services was inadequate (37% vs 13%). Both groups agreed that surgical treatments are complex and should be performed in the setting of a multidisciplinary team.

CONCLUSIONS

Surgeons and nonsurgeons differ in their views regarding upper extremity reconstructive surgery for CP. Barriers to reconstruction may be addressed by performing higher level research, implementing multispecialty educational outreach, developing objective referral criteria, increasing surgical remuneration, improving access to trained upper extremity surgeons, and implementing multidisciplinary CP clinics.

Assessment, goal setting, and botulinum neurotoxin a therapy in the management of post-stroke spastic movement disorder: updated perspectives on best practice

INTRODUCTION

Post-stroke spastic movement disorder (PS-SMD) appears up to 20% in the first week following stroke and 40% in the chronic phase. It may create major hurdles to overcome in early stroke rehabilitation and as one relevant factor that reduces quality of life to a major degree in the chronic phase.

AREAS COVERED

In this review, we discuss predictors,early identification, clinical assessments, goal setting, and management in multiprofessional team, including Botulinum neurotoxin A (BoNT-A) injection for early and chronic management of PS-SMD.

EXPERT OPINION

The earlier PS-SMD is recognized and managed, the better the outcome will be. The comprehensive management in the subacute or chronic phase of PS-SMD with BoNT-A injections requires detailed assessment, patient-centered goal setting, technical-guided injection, effective dosing of BoNT-A per site, muscle, and session and timed adjunctive treatment, delivered in a multi-professional team approach in conjunction with physical treatment. Evidence-based data showed BoNT-A injections are safe and effective in managing focal, multifocal, segmental PS-SMD and its complications. If indicated, BoNT-A therapy should be accompanied with adjunctive treatment in adequate time slots. BoNT-A could be added to oral, intrathecal, and surgical treatment in severe multisegmental or generalized PS-SMD to reach patient/caregiver's goals, especially in chronic PS-SMD.

The Spastic Upper Extremity in Children: Multilevel Surgical Decision-making

Multilevel surgery for upper extremity spasticity is the current surgical standard. While the literature details surgical techniques and outcomes, a comprehensive guide to surgical planning is lacking. Patients commonly present with posturing into shoulder internal rotation, elbow flexion, forearm pronation, wrist flexion with ulnar deviation, finger flexion, and thumb adduction, although variations exist. Multiple surgical options exist for each segment; therefore, repeated examinations for contracture, pathologic laxity, and out of phase activity are necessary to optimize the surgical plan. To avoid decreasing function, one must carefully balance the benefits of contracture release and tendon transfers with their weakening effects. In certain cases, stability from joint fusion outweighs the loss of motion. Failure to recognize dynamic posturing, grasp and release requirements, or hand intrinsic spasticity can worsen function and cause new deformities. Surgical indications are formulated for individual deformity patterns and severity along with personal/family goals. General comprehension, voluntary control, and sensation, although not modifiable, influence decision making and are prognostic indicators. Functional improvement is unlikely without preexisting voluntary control, but appearance and visual feedback may be improved by repositioning nonetheless. Appropriate interventions and management of expectations will optimize limb appearance and function while avoiding unexpected sequelae.