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De Lepeleere B, Fitoussi F. Elbow Flexor Release Combined With Selective Neurectomy of Musculocutaneous Nerve for Spastic Elbow Flexion Deformity in Children and Adolescents. J Pediatr Orthop 2024:01241398-990000000-00567. [PMID: 38770666 DOI: 10.1097/bpo.0000000000002729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Spasticity of the elbow flexors causes a dynamic and/or static elbow flexion deformity. This position interferes with the functional use of the hand, is aesthetically unpleasant and can cause problems with hygiene and comfort. A lengthening procedure of elbow flexor muscles can improve elbow posture and range of motion. However, causal spasticity is not addressed directly. Selective neurectomy of the musculocutaneous nerve has a direct effect on underlying spasticity but is not sufficient when contracture is present. In this study, we examine the long-term results of a combined surgical approach: a release procedure of the elbow flexors and selective neurectomy of the musculocutaneous nerve. METHODS A retrospective study of 14 patients with spastic flexion deformity of the elbow was performed. After a mean follow-up of 52.6 months (SD 33, range 12 to 113), the results of the combined surgical approach were evaluated. Spontaneous position of the elbow and active and passive range of motion were assesses using goniometry. Spasticity was assessed using the Modified Ashworth Scale. Function of the affected upper limb before and after surgery was assessed by the House functional classification. Patient and caretaker's satisfaction were assessed using a visual analogue scale. RESULTS The mean decrease of passive elbow extension deficit was 34 degrees (SD 21.3, P<0.05). Active elbow extension increased with a mean of 41 degrees (SD 16.5, P<0.05). Spontaneous position elbow flexion decreased by a mean of 40 degrees (SD 21.1, P<0.05).The Modified Ashworth score decreased significantly (P<0.05) from 3.27 (range 1 to 4) preoperatively to 0.64 (range 0 to 4) postoperatively.The difference between the House score preoperatively and postoperatively was not significant (P=0.180). Mean patient satisfaction was 8.2/10 (SD 2.7, range 2 to 10) and mean caregiver satisfaction was 7.1/10 (SD 2.7, range 1 to 10). CONCLUSION A combined surgical approach to elbow flexion deformity in the form of a lengthening procedure and selective neurectomy of the elbow flexors result in a significant and sustained improvement of the spontaneous position, active and passive elbow extension and elbow flexor spasticity and high patient and caregiver satisfaction. LEVEL OF EVIDENCE Case series, level IV.
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Affiliation(s)
- Bram De Lepeleere
- Department of Physical Medicine and Orthopaedic Surgery, Ghent University, Corneel Heymanslaan, Ghent, Belgium
| | - Frank Fitoussi
- Department of Pediatric Orthopedic and Reconstructive Surgery, Sorbonne Medical University, Trousseau Hospital, Paris, France
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2
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Onggo JR, Chua NSH, Onggo JD, Wang KK, Ek ET. Clinical Outcomes Following Surgical Management of Post-Traumatic Elbow Contractures in the Pediatric Age Group: A Meta-Analysis and Systematic Review. J Hand Surg Am 2024:S0363-5023(24)00026-1. [PMID: 38416094 DOI: 10.1016/j.jhsa.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 12/15/2023] [Accepted: 01/03/2024] [Indexed: 02/29/2024]
Abstract
PURPOSE Post-traumatic elbow stiffness is a common occurrence resulting in potentially substantial functional limitations in both daily activities and recreational endeavors. In children, this can be particularly difficult given the early stages of childhood and development and the challenges of rehabilitation. Several studies have reported favorable results of elbow contracture releases in children, resulting in improvements in outcomes. This meta-analysis aimed to determine the efficacy and safety of elbow contracture releases in the pediatric population (<18 years), along with subgroup analyses comparing age groups, operative approach, and post-traumatic versus nontraumatic etiologies. METHODS Meta-analysis was performed with a multidatabase search (PubMed, OVID, EMBASE, and Medline) according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines on September 25, 2020. Data from all published literature meeting inclusion criteria were extracted and analyzed. RESULTS Seven studies were included, comprising 114 post-traumatic elbow contractures. Mean age was 13.7 years. Contracture releases of the elbow led to improvements in flexion-extension arc of motion by 48º, and pronosupination arc of motion by 22º. Subgroup analysis comparing age groups of <10, 10-14 and 15-18 years showed greater improvements in flexion-extension arc in the older age group, whereas subgroup analysis comparing injury patterns revealed a larger improvement in pronosupination motion for radial head fractures. Comparing open and arthroscopic procedures, open releases had greater improvement in both flexion-extension and pronosupination motion by 18º and 21º, respectively, although there were limited patients in the arthroscopy group. CONCLUSION Operative management of pediatric elbow contractures is effective. Older children, children with radial head fractures, and those receiving open contracture releases may be more likely to have greater improvements. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- James R Onggo
- Department of Surgery, Monash Medical Centre, Monash University, Melbourne, VIC, Australia; Department of Orthopaedic Surgery, Box Hill Hospital, Victoria, Australia
| | - Nina S H Chua
- Department of Orthopaedic Surgery, Box Hill Hospital, Victoria, Australia
| | - Jason D Onggo
- Department of Orthopaedic Surgery, Box Hill Hospital, Victoria, Australia
| | - Kemble K Wang
- Department of Orthopaedic Surgery, Box Hill Hospital, Victoria, Australia; Department of Orthopaedic Surgery, Royal Children's Hospital, Victoria, Australia
| | - Eugene T Ek
- Department of Surgery, Monash Medical Centre, Monash University, Melbourne, VIC, Australia; Melbourne Orthopaedic Group, Melbourne, VIC, Australia.
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3
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Luo W, Nixon M. Surgical management of the spastic elbow. Shoulder Elbow 2023; 15:534-543. [PMID: 37811394 PMCID: PMC10557929 DOI: 10.1177/17585732221102399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/02/2022] [Accepted: 05/03/2022] [Indexed: 10/10/2023]
Abstract
Background We performed a retrospective review of patients undergoing surgery for elbow spasticity. We present our findings and expected outcomes according to degree of elbow fixed flexion contracture. Methods Data collected included age, Modified Ashworth Score, pre and post-operative range of motion, indications for surgery and the Goal Attainment Score. Contracture severity was classified into five groups based on goniometric measurements. Surgical procedures were categorised into three groups. Results A total of 114 elbows underwent surgical release. The mean age at surgery was 18.5 years and the mean follow-up was 20 months. Preoperatively, the median Modified Ashworth Score was 2 and the mean contracture was 68° (35° fixed and 33° dynamic). The median number of structures released was 3 (range: 1-6). Surgical procedures were classified as biceps sparing (27%), biceps lengthening (53%) and extended releases (18%). Mean improvement in extension was 59°, and the mean improvement in Goal Attainment Score was 36 (mean attainment score 62). The mean residual contracture was 9°. Patient satisfaction was high with over 90% of surgical indications met. Discussion Contracture severity of the spastic elbow can be categorised by degree of fixed flexion deformity and therefore treatment can be allocated accordingly.
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Affiliation(s)
| | - Matthew Nixon
- Countess of Chester Hospital, Chester, UK
- Royal Manchester Children's Hospital, Manchester, UK
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Loewenstein SN, Angulo-Parker F, Timsina L, Adkinson J. Barriers to Upper Extremity Reconstruction for Patients With Cerebral Palsy. Hand (N Y) 2022; 17:926-932. [PMID: 33319587 PMCID: PMC9465801 DOI: 10.1177/1558944720976413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
| | | | - Lava Timsina
- Indiana University School of Medicine,
Indianapolis, USA
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5
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Martinez-Lozano E, Beeram I, Yeritsyan D, Grinstaff MW, Snyder BD, Nazarian A, Rodriguez EK. Management of arthrofibrosis in neuromuscular disorders: a review. BMC Musculoskelet Disord 2022; 23:725. [PMID: 35906570 PMCID: PMC9336011 DOI: 10.1186/s12891-022-05677-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 07/20/2022] [Indexed: 11/20/2022] Open
Abstract
Arthrofibrosis, or rigid contracture of major articular joints, is a significant morbidity of many neurodegenerative disorders. The pathogenesis depends on the mechanism and severity of the precipitating neuromuscular disorder. Most neuromuscular disorders, whether spastic or hypotonic, culminate in decreased joint range of motion. Limited range of motion precipitates a cascade of pathophysiological changes in the muscle-tendon unit, the joint capsule, and the articular cartilage. Resulting joint contractures limit functional mobility, posing both physical and psychosocial burdens to patients, economic burdens on the healthcare system, and lost productivity to society. This article reviews the pathophysiology of arthrofibrosis in the setting of neuromuscular disorders. We describe current non-surgical and surgical interventions for treating arthrofibrosis of commonly affected joints. In addition, we preview several promising modalities under development to ameliorate arthrofibrosis non-surgically and discuss limitations in the field of arthrofibrosis secondary to neuromuscular disorders.
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Affiliation(s)
- Edith Martinez-Lozano
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 02215, USA
| | - Indeevar Beeram
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 02215, USA
| | - Diana Yeritsyan
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 02215, USA
| | - Mark W Grinstaff
- Departments of Biomedical Engineering, Chemistry, and Medicine, Boston University, 330 Brookline Avenue, Stoneman 10, Boston, MA, 02215, USA
| | - Brian D Snyder
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 02215, USA.,Department of Orthopaedic Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02215, USA
| | - Ara Nazarian
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 02215, USA.,Department of Orthopaedic Surgery, Yerevan State Medical University, Yerevan, 0025, Armenia
| | - Edward K Rodriguez
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 02215, USA.
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The Spastic Upper Extremity in Children: Multilevel Surgical Decision-making. J Am Acad Orthop Surg 2021; 29:e416-e426. [PMID: 33883454 DOI: 10.5435/jaaos-d-20-00719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 01/11/2021] [Indexed: 02/01/2023] Open
Abstract
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.
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Tranchida GV, Van Heest A. Preferred options and evidence for upper limb surgery for spasticity in cerebral palsy, stroke, and brain injury. J Hand Surg Eur Vol 2020; 45:34-42. [PMID: 31594425 DOI: 10.1177/1753193419878973] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Surgical interventions for the spastic upper extremity secondary to stroke, traumatic brain injury, and cerebral palsy aim to correct the common deformities of elbow flexion, forearm pronation, wrist and finger flexion, ulnar deviation, and thumb-in-palm deformity. After appropriate evaluation, as well as determining the goals of surgery, deformity correction can be achieved through single-event, multi-level surgery. Surgery includes a combination of soft tissue lengthening, tendon transfer, and joint stabilization procedures. Surgical treatment for shoulder adduction/internal rotation, elbow flexion, forearm pronation, wrist flexion, thumb-in-palm, and clenched fist deformities due to spasticity are discussed, and treatment outcomes are reviewed.
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Affiliation(s)
- Geneva V Tranchida
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Ann Van Heest
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
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Louwers A, Warnink‐Kavelaars J, Daams J, Beelen A. Effects of upper extremity surgery on activities and participation of children with cerebral palsy: a systematic review. Dev Med Child Neurol 2020; 62:21-27. [PMID: 31334566 PMCID: PMC6916411 DOI: 10.1111/dmcn.14315] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 05/28/2019] [Accepted: 05/31/2019] [Indexed: 11/29/2022]
Abstract
AIM To evaluate and synthesize the evidence for effects of upper extremity surgery (UES) on activities and participation of children and adolescents with cerebral palsy (CP). METHOD The databases MEDLINE, Embase, and PsycINFO were searched for publications up to September 2018. Studies included were comparative studies with or without concurrent comparison groups or case series with pretest/posttest outcomes with a minimal sample size of 10 participants; those that reported the effects of UES with a follow-up time of at least 5 months; those including patients diagnosed with CP aged up to 20 years; and those that used a validated activity-based instrument. Risk of bias was assessed using the ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tool and quality assessment was performed using the Grading of Recommendations Assessment, Development and Evaluation. RESULTS Twelve studies, involving 310 children and adolescents, were included. The ability and perception of the patient to use the hand(s) and perform activities (measured with the Shriners Hospital Upper Extremity Evaluation, Assisting Hand Assessment, and House Functional Classification) improved significantly after UES. The quality of evidence was very low for each of the activity outcomes of interest. INTERPRETATION The very low evidence prohibits recommendations on the use of UES to guide clinical practice. More high-quality comparative studies are needed to obtain better insight into the effects of UES on activities and participation. WHAT THIS PAPER ADDS Low quality of evidence for effects of upper extremity surgery (UES) on activities and participation. Limited evidence for improvement in activities and participation after UES.
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Affiliation(s)
- Annoek Louwers
- Department of Rehabilitation, Amsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | | | - Joost Daams
- Medical Library, Amsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - Anita Beelen
- Department of Rehabilitation, Amsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
- Center of Excellence in Rehabilitation MedicineUMC Utrecht Brain Center, University Medical Center Utrecht, De Hoogstraat RehabilitationUtrechtthe Netherlands
- Department of Rehabilitation, Physical Therapy Science and SportsUMC Utrecht Brain Center, University Medical Center Utrechtthe Netherlands
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Park KB, Park H, Park BK, Abdel-Baki SW, Kim HW. Clinical and Gait Parameters Related to Pelvic Retraction in Patients with Spastic Hemiplegia. J Clin Med 2019; 8:jcm8050679. [PMID: 31091787 PMCID: PMC6571873 DOI: 10.3390/jcm8050679] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/01/2019] [Accepted: 05/13/2019] [Indexed: 11/20/2022] Open
Abstract
Pelvic retraction during walking is a common finding seen in patients with spastic hemiplegia. However, potential factors related to this condition have not been comprehensively examined in a systemic manner in previous studies. The purpose of this study was to elucidate any clinical and gait parameters related to pelvic retraction in patients with hemiplegic cerebral palsy. A total of 212 independent ambulatory patients were enrolled in the study. Group I consisted of 113 patients who had persistent pelvic retraction, and Group II of 99 with a normal range of pelvic rotation throughout the gait cycle as evidenced by kinematic analysis. A multivariate logistic regression analysis using a clustering technique was performed, with use of eight gait factors and five clinical factors. Decreased ankle dorsiflexion, increased hip internal rotation, increased anterior pelvic tilt, the Winters classification type II, and asymmetrical posturing of the upper extremity during gait were found to be related to pelvic retraction. This is the only study including a broader array of assessment domains of both clinical and gait parameters with a considerably large and homogenous population with hemiplegia. Further studies will be needed to see whether the rectification of those parameters may improve abnormal gait and pelvic retraction in hemiplegia.
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Affiliation(s)
- Kun-Bo Park
- Division of Pediatric Orthopaedic Surgery, Severance Children's Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea.
| | - Hoon Park
- Department of Orthopaedic Surgery, Gangnam Severance Hospital, Seoul 06273, Korea.
| | - Byoung Kyu Park
- Department of Orthopaedic Surgery, Inje University Haeundae Paik Hospital, Busan 48108, Korea.
| | - Sharkawy Wagih Abdel-Baki
- Division of Pediatric Orthopaedic Surgery, Severance Children's Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea.
| | - Hyun Woo Kim
- Division of Pediatric Orthopaedic Surgery, Severance Children's Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea.
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Abstract
A spastic limb refers to one with increased tone. This commonly results from an upper motor neuron injury, which, in turn, leads to disinhibition of reflex arcs. At the level of the elbow, affected individuals typically exhibit a flexion posture secondary to spastic contracture of the biceps, brachialis, and brachioradialis muscles. Surgical treatment aims to improve access for hygiene, function, and cosmetic appearance of the affected limb. The specific surgical intervention performed depends on the degree of elbow flexion contracture and whether there is an associated joint contracture or soft tissue deficit.
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Affiliation(s)
- Aaron Berger
- Division of Plastic Surgery, Nicklaus Children's Hospital, 3100 Southwest 62 Avenue, Miami, FL 33155, USA.
| | - Saoussen Salhi
- Division of Plastic Surgery, Nicklaus Children's Hospital, 3100 Southwest 62 Avenue, Miami, FL 33155, USA
| | - Monica Payares-Lizano
- Department of Orthopaedic Surgery, Nicklaus Children's Hospital, 3100 Southwest 62nd Avenue, Miami, FL 33155, USA
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Abstract
Upper extremity contractures in the spastic patient may result from muscle spasticity, secondary muscle contracture, or joint contracture. Knowledge of the underlying cause is critical in planning successful treatment. Initial management consists of physical therapy and splinting. Botulinum toxin can be helpful, as a therapeutic treatment in relieving spasticity and as a diagnostic tool in determining the underlying cause of the contracture. Surgical management options include release or lengthening of the causative muscle/tendon unit and joint capsular release, as required. Postoperative splinting is important to maintain the improved range of motion and protect any associated tendon lengthening or transfer.
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Affiliation(s)
- Kristi S Wood
- Department of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, 5th Floor, New York, NY 10021, USA
| | - Aaron Daluiski
- Department of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, 5th Floor, New York, NY 10021, USA; Department of Hand and Upper Extremity, Hospital for Special Surgery, 523 East 72nd Street, 4th Floor, New York, NY 10021, USA.
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12
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Abstract
Surgical interventions for the spastic upper extremity aim to correct the common deformities of elbow flexion, forearm pronation, wrist flexion and ulnar deviation, and thumb-in-palm deformity. One goal is achieving optimal function and improved limb positioning. Aesthetics of the limb have a profound impact on self-esteem and satisfaction. Surgical deformity correction has not reliably been shown to improve sensory function such as stereognosis. Validated outcome measures are used to present outcomes after surgical treatment of the spastic upper extremity as it relates to motor function and limb positioning, sensory function, and self-esteem.
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Affiliation(s)
- Geneva V Tranchida
- Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South, Suite R200, Minneapolis, MN 55455, USA
| | - Ann E Van Heest
- Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South, Suite R200, Minneapolis, MN 55455, USA.
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13
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Abstract
BACKGROUND Children with hemiplegic cerebral palsy (hCP) exhibit a typical posture of elbow flexion during gait. However, the change in elbow kinematics and symmetry during gait across age span in both hCP and typically developing (TD) children is not well described. The aim of this study was to quantify the change in elbow kinematics and symmetry across age span in hCP children compared with TD children. METHODS Upper extremity kinematic data were extracted and analyzed from a database for gait studies performed between 2009 and 2015. A total of 35 hCP and 51 TD children between the ages of 4 and 18 (mean age: TD=11.2±0.6, hCP=9.8±0.5) met inclusionary criteria. The groups were further subdivided into 3 age categories: 4 to 7, 8 to 11, 12+ years old. Elbow angles were extracted and peak elbow flexion, overall range of motion during gait, and asymmetry indices were calculated. A 1-way analysis of variance was performed on each group with post hoc Tukey honestly significant difference pairwise comparisons. RESULTS Peak elbow flexion during gait increased with age in TD children (P<0.05) and decreased with age in hCP children on the affected side (P<0.05). There was no change on the less affected side of hCP children. TD children demonstrated significantly less elbow flexion (mean=51.9±2.1 deg.) compared with the affected side in hCP (mean=82.1±3.8 deg.) across all age categories (P<0.05). There was no change in elbow asymmetry index (0=perfect symmetry) across age in either controls or hCP children; however, there were differences between hCP and TD groups in younger age groups (TD=28, hCP=62, P<0.05) that resolved by adolescence (TD=32, hCP=40). CONCLUSIONS During gait, hCP children have greater peak elbow flexion on the affected side than do TD children. Peak elbow flexion angle converged between the 2 groups with age, decreasing in hCP children and increasing in TD children. Furthermore, elbow symmetry during gait improves with age in hCP children, approximating symmetry of TD children by adolescence. These findings have implications for both consideration and optimal timing of surgical intervention to improve elbow flexion in children with hCP. LEVEL OF EVIDENCE Level III-retrospective case-control study.
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Thieffry C, Chenin L, Foulon P, Havet E, Peltier J. Microsurgical anatomy of branches of musculocutaneous nerve: clinical relevance for spastic elbow surgery. Surg Radiol Anat 2017; 39:773-778. [PMID: 28039506 DOI: 10.1007/s00276-016-1800-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 12/15/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE The neurotomy of musculocutaneous nerve is a treatment for patients who suffer from spastic elbow flexion when medical and reeducative treatments have failed. It consists in sectioning motor branches of musculocutaneous nerve which are destined to the biceps brachii and brachialis muscles, both being the main elbow flexor muscles. The aim of this study was to analyse the distance, where each motor branch arises from the musculocutaneous nerve to both biceps brachii and brachialis muscles, to establish precisely the localisation and length of the necessary incision to reach its branches for surgery. MATERIALS AND METHODS Eighteen musculocutaneous nerves from ten cadavers were dissected. None of them reported with a previous pathology. The cadavers were laid on the back with 30-35° of abduction, a complete extension, and supination of the upper limb. RESULTS The localization of motor branches was to be found in the middle third of the upper arm, with an average from the base of the humeral major tubercle of 11.46, 12.40, and 12.87 cm for the biceps brachii and 16.36, 19.10, and 16.88 cm for the brachialis muscle. CONCLUSION The incision needed to reach the motor branches of the musculocutaneous nerve should be localised between 10 and 20 cm from the major humeral tubercle and may be shorter than usual.
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Affiliation(s)
- C Thieffry
- Department of Organogenesis and Anatomy, Universite de Picardie Jules Verne, 3 rue des Louvels, 80036, Amiens, France.
| | - L Chenin
- Department of Organogenesis and Anatomy, Universite de Picardie Jules Verne, 3 rue des Louvels, 80036, Amiens, France
| | - P Foulon
- Department of Organogenesis and Anatomy, Universite de Picardie Jules Verne, 3 rue des Louvels, 80036, Amiens, France
| | - E Havet
- Department of Organogenesis and Anatomy, Universite de Picardie Jules Verne, 3 rue des Louvels, 80036, Amiens, France
| | - J Peltier
- Department of Organogenesis and Anatomy, Universite de Picardie Jules Verne, 3 rue des Louvels, 80036, Amiens, France
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Shierk A, Lake A, Haas T. Review of Therapeutic Interventions for the Upper Limb Classified by Manual Ability in Children with Cerebral Palsy. Semin Plast Surg 2016; 30:14-23. [PMID: 26869859 DOI: 10.1055/s-0035-1571256] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The aim of this literature review was to assemble an inventory of intervention strategies utilized for children diagnosed with cerebral palsy (CP) based on the Manual Ability Classification System (MACS). The purpose of the inventory is to guide physicians and therapists in intervention selection aimed at improving upper limb function in children with CP. The following databases were searched: CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane Database of Systematic Reviews, ERIC (Educational Research Information Center), Google Scholar, OTSeeker (Occupational Therapy Systematic Evaluation of Evidence), OVID (Ovid Technologies, Inc.), and PubMed. Inclusion criteria were whether the study (1) identified MACS levels of participants, and (2) addressed the effectiveness of intervention on upper limb function. Overall, 74 articles met the inclusion criteria. The summarized data identified 10 categories of intervention. The majority of participants across studies were MACS level II. The most frequently cited interventions were constraint-induced movement therapy (CIMT), bimanual training, and virtual reality and computer-based training. Multiple interventions demonstrated effectiveness for upper limb improvement at each MACS level. However, there is a need for additional research for interventions appropriate for MACS levels IV and V. To fully develop an intervention inventory based on manual ability, future studies need to report MACS levels of participants, particularly for splinting and therapy interventions used in combination with surgery.
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Affiliation(s)
- Angela Shierk
- Occupational Therapy, Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Amy Lake
- Occupational Therapy, Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Tara Haas
- Physical Medicine and Rehabilitation, Texas Children's Hospital, Houston, Texas
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16
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Management of the spastic wrist and hand in cerebral palsy. J Hand Surg Am 2015; 40:1035-40; quiz 1041. [PMID: 25841769 DOI: 10.1016/j.jhsa.2014.11.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 11/19/2014] [Accepted: 11/20/2014] [Indexed: 02/02/2023]
Abstract
Research from the last 5 years on the pathophysiology and treatment of upper extremity sequelae of cerebral palsy (CP) is presented. The development of new treatments of CP-affected limbs, utilizing the brain's inherent neuroplasticity, remains an area of promising and active research. Functional magnetic resonance imaging scans have evaluated the role of neuroplasticity in adapting to the initial central nervous system insult. Children with CP appear to have greater recruitment of the ipsilateral brain for motor and sensory functions of the affected upper limb. Studies have also shown that constraint-induced movement therapy results in localized increase in gray matter volume of the sensorimotor cortex contralateral to the affected arm targeted during rehabilitation. Recent therapy interventions have emphasized the role of home therapy programs, the transient effects of splinting, and the promise of constraint-induced movement therapy and bimanual hand training. The use of motion laboratory analysis to characterize the movement pattern disturbances in children with CP continues to expand. Classification systems for CP upper limb continue to expand and improve their reliability, including use of the House Classification, the Manual Ability Classification System, and the Shriner's Hospital Upper Extremity Evaluation. Surgical outcomes have greater patients' satisfaction when they address functional limitations, also in addition to aesthetics, which may improve patients' self-esteem. Surgical techniques for elbow, wrist, fingers, and thumb continue to be refined. Research into each of these areas continues to expand our understanding of the nervous system insults that cause CP, how they may be modified, and how hand surgeons can continue to serve patients by improving their upper limb function and aesthetics.
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17
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Bunata R, Icenogle K. Cerebral palsy of the elbow and forearm. J Hand Surg Am 2014; 39:1425-32. [PMID: 24969499 DOI: 10.1016/j.jhsa.2013.12.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Revised: 12/17/2013] [Accepted: 12/18/2013] [Indexed: 02/02/2023]
Abstract
Management of elbow and forearm involvement in cerebral palsy has evolved over the last 3 decades with a better understanding of its neuropathophysiology, improved outcome measures, and evolving therapy protocols. Current nonoperative and surgical treatment methods are discussed. The use of standard function measuring instruments and encouragement of the participation in research will hopefully result in more accurate outcome information and, thereby, refine our techniques and rehabilitation methods.
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Affiliation(s)
- Robert Bunata
- University of North Texas Health Science Center/Cook Children's Hospital; and the University of North Texas Health Science Center, Tarrant County Affiliated Orthopedic Residency Program, Fort Worth, TX.
| | - Kurt Icenogle
- University of North Texas Health Science Center/Cook Children's Hospital; and the University of North Texas Health Science Center, Tarrant County Affiliated Orthopedic Residency Program, Fort Worth, TX
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18
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Gong HS, Cho HE, Chung CY, Park MS, Lee HJ, Baek GH. Early results of anterior elbow release with and without biceps lengthening in patients with cerebral palsy. J Hand Surg Am 2014; 39:902-9. [PMID: 24674610 DOI: 10.1016/j.jhsa.2014.02.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 02/13/2014] [Accepted: 02/14/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the effect of partial biceps lengthening on elbow flexion posture and active elbow flexion and extension in patients with cerebral palsy. METHODS We retrospectively reviewed 29 patients with cerebral palsy who underwent anterior elbow release as part of multilevel upper extremity surgery. The early series of the patients (N = 14; group 1) had lacertus fibrosus division, brachialis fractional lengthening, and denuding of the pretendinous adventitia off the biceps tendon. The later series of patients (N = 15; group 2) had partial biceps tendon lengthening in addition to the procedures in group 1. We compared the 2 sets of patients for elbow flexion posture, active elbow flexion and extension, forearm rotation, and House scores, with mean follow-ups of 72 months for group 1 and 31 months for group 2. RESULTS The 2 groups were comparable in terms of mean age, number of procedures, and preoperative House scores. Group 2 patients had more improvement in flexion posture (53° vs. 44°) and active extension (23° vs. 15°) than group 1 postoperatively. However, group 2 had a mean decrease of 7° in active elbow flexion, whereas group 1 had no changes. There was no difference in forearm supination or in the improvement of House scores between groups. CONCLUSIONS Early results of partial lengthening of the biceps tendon showed that it may improve elbow flexion posture and active elbow extension in patients with flexion deformity in cerebral palsy. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.
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Affiliation(s)
- Hyun Sik Gong
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea; Albert Einstein College of Medicine, Bronx, NY; Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea.
| | - Hoyune Esther Cho
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea; Albert Einstein College of Medicine, Bronx, NY; Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Chin Youb Chung
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea; Albert Einstein College of Medicine, Bronx, NY; Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Moon Seok Park
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea; Albert Einstein College of Medicine, Bronx, NY; Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Hyuk Jin Lee
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea; Albert Einstein College of Medicine, Bronx, NY; Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Goo Hyun Baek
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea; Albert Einstein College of Medicine, Bronx, NY; Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
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Dy CJ, Pean CA, Hearns KA, Swanstrom MM, Janowski LC, Carlson MG. Long-term results following surgical treatment of elbow deformity in patients with cerebral palsy. J Hand Surg Am 2013; 38:2432-6. [PMID: 24275052 DOI: 10.1016/j.jhsa.2013.09.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 09/13/2013] [Accepted: 09/17/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the long-term results of surgical intervention for elbow flexion deformity in cerebral palsy. We hypothesized that improvements in elbow extension and flexion posture angle at ambulation would be maintained over time with preservation of active flexion. METHODS A total of 23 patients (23 elbows) were available for long-term follow-up. Patients had fixed elbow contractures less than 45° and were treated with partial elbow muscle lengthening. Active and passive range of motion and elbow flexion posture during ambulation were measured at each follow-up, and longitudinal results were compared. RESULTS Active extension and flexion posture angle during ambulation improved 12° and 63°, respectively, with an 8° loss of active flexion. CONCLUSIONS Soft tissue lengthening of the anterior elbow can provide statistically significant lasting improvements in active extension and flexion posture during ambulation in patients with cerebral palsy. Our long-term findings substantiate previously reported short-term results. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Christopher J Dy
- Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, NY
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