Neurology and orthopaedics

Classification of Ataxic Gait

Gait disorders accompany a number of neurological and musculoskeletal disorders that significantly reduce the quality of life. Motion sensors enable high-quality modelling of gait stereotypes. However, they produce large volumes of data, the evaluation of which is a challenge. In this publication, we compare different data reduction methods and classification of reduced data for use in clinical practice. The best accuracy achieved between a group of healthy individuals and patients with ataxic gait extracted from the records of 43 participants (23 ataxic, 20 healthy), forming 418 segments of straight gait pattern, is 98% by random forest classifier preprocessed by t-distributed stochastic neighbour embedding.

Reliability of IMU-Derived Static Balance Parameters in Neurological Diseases

Static balance is a commonly used health measure in clinical practice. Usually, static balance parameters are assessed via force plates or, more recently, with inertial measurement units (IMUs). Multiple parameters have been developed over the years to compare patient groups and understand changes over time. However, the day-to-day variability of these parameters using IMUs has not yet been tested in a neurogeriatric cohort. The aim of the study was to examine day-to-day variability of static balance parameters of five experimental conditions in a cohort of neurogeriatric patients using data extracted from a lower back-worn IMU. A group of 41 neurogeriatric participants (age: 78 ± 5 years) underwent static balance assessment on two occasions 12-24 h apart. Participants performed a side-by-side stance, a semi-tandem stance, a tandem stance on hard ground with eyes open, and a semi-tandem assessment on a soft surface with eyes open and closed for 30 s each. The intra-class correlation coefficient (two-way random, average of the k raters' measurements, ICC2, k) and minimal detectable change at a 95% confidence level (MDC95%) were calculated for the sway area, velocity, acceleration, jerk, and frequency. Velocity, acceleration, and jerk were calculated in both anterior-posterior (AP) and medio-lateral (ML) directions. Nine to 41 participants could successfully perform the respective balance tasks. Considering all conditions, acceleration-related parameters in the AP and ML directions gave the highest ICC results. The MDC95% values for all parameters ranged from 39% to 220%, with frequency being the most consistent with values of 39-57%, followed by acceleration in the ML (43-55%) and AP direction (54-77%). The present results show moderate to poor ICC and MDC values for IMU-based static balance assessment in neurogeriatric patients. This suggests a limited reliability of these tasks and parameters, which should induce a careful selection of potential clinically relevant parameters.

Novel ATL1 mutation in a Chinese family with hereditary spastic paraplegia: A case report and review of literature

BACKGROUND

Hereditary spastic paraplegias (HSPs) refer to a group of heterogeneous neurodegenerative diseases characterized by lower limbs spasticity and weakness. So far, over 72 genes have been found to cause HSP (SPG1-SPG72). Among autosomal dominant HSP patients, spastic paraplegia 4 (SPG4/SPAST) gene is the most common pathogenic gene, and atlastin-1 (ATL1) is the second most common one. Here we reported a novel ATL1 mutation in a Chinese spastic paraplegia 3A (SPG3A) family, which expands the clinical and genetic spectrum of ATL1 mutations.

CASE SUMMARY

A 9-year-old boy with progressive spastic paraplegia accompanied by right hearing loss and mental retardation for five years was admitted to our hospital. Past history was unremarkable. The family history was positive, and his grandfather and mother had similar symptoms. Neurological examinations revealed hypermyotonia in his lower limbs, hyperreflexia in knee reflex, bilateral positive Babinski signs and scissors gait. The results of blood routine test, liver function test, blood glucose test, ceruloplasmin test and vitamin test were all normal. The serum lactic acid level was significantly increased. The testing for brainstem auditory evoked potential demonstrated that the right side hearing was impaired while the left was normal. Magnetic resonance imaging showed mild atrophy of the spinal cord. The gene panel test revealed that the proband carried an ATL1 c.752A>G p.Gln251Arg (p.Q251R) mutation, and Sanger sequencing confirmed the existence of family co-segregation.

CONCLUSION

We reported a novel ATL1 Q251R mutation and a novel clinical phenotype of hearing loss in a Chinese SPG3A family.

Our experience regarding rehabilitative, orthopedic integrative interdisciplinary approach in patients with disabling neurological posttraumatic sequelae. Case series and some related literature pointing

Abstract Introduction Traumatic brain injury (TBI) and / or spinal cord injury (SCI) usually occur in a polytraumatic context, and may produce catastrophic central nervous system (CNS) damages and secondarily extensive dysfunctional biomechanical alterations. This study aims to illustrate the interdisciplinary collaboration between neurorehabilitation and orthopedic clinics in our hospital, focusing on the results of surgical interventions intended to correct the fixed-flexion deformity of knees, in patients with disabling sequelae after CNS severe lesions. Material and methods Between 2005-2018, in the Neuromuscular Rehabilitation Clinic of Teaching Emergency Hospital "Bagdasar-Arseni", 13 young patients (mean age 37.4 +/- 12.6; median 31; limits 26-43) with multiple articular stiffness and joint deposturing sequelae after severe CNS trauma have been transferred from other medical units. Twelve had bilateral knee flexion contractures, two associated additional elbow stiffness, and in three patients ectopic ossifications of the hips, with ankylosis in extension or painful flexion were found. Patients were subsequently transferred for iterative orthopedic interventions: hamstring lengthening (pes anserinus and femoral biceps tendon transpositions) in 12 cases, associated with posterior knee capsulotomy, traction and/or resection of neurogenic heterotopic ossification around the knee or hip joints and casting in 8 of them. All orthopedic interventions were followed by progressive rehabilitation programs. Spasticity was assessed with modified Ashworth scale (mAS). In pre-/ and post orthopedic surgery, all patients were assessed using an adaptation for adults of the Gross Motor Function Classification Scale, Expanded and Revised (GMFCS – E&R). Results Twelve patients had knee joint stiffness and chronic flexion contracture: 77% were severely limited in their walking ability, depending on wheelchair (GMFCS – E&R level IV), respectively 23% were bedridden, non-ambulate and totally dependent in all aspects of care (GMFCS – E&R level V). Knee orthopedic serial interventions were followed by iterative, individualized rehabilitation treatments, and 50% subjects have regain their capacity to walk independently (GMFCS – E&R level II), respectively 50% succeeded to walked with assistive devices (GMFCS – E&R level III). Discussion Both neuro-muscular system deficits and joint disorders can produce locomotor system abnormalities, joint complications and limb dysfunctional problems. These disturbances represent targets and therapeutic objectives for rehabilitation. Chronic knee flexion contracture, stiff elbows and/or hips, periarticular neurogenic heterotopic ossification: all represents major challenges in the complex management of patients with sequelae after CNS severe traumatic events. Posterior capsulotomy addressed to a stiffed, distorted knee joint, corrects the limb axis and expands the range of motion (through the angle gained by the eliminated flexion contracture), and sometimes restores the patient's ability to walk. Serial orthopedic interventions, followed by sustained postoperative rehabilitation, had a decisive influence on obtaining good functional results. Conclusions Comprehensive, multiprofessional approach and collaboration between neurorehabilitation and orthopedic teams are essential for the therapeutic management of patients with severe contractures post neuraxial lesions. Proper evaluation and goal setting are mandatory for rehabilitative management, pre-/ and post orthopedic corrective surgery. Harmonized timing for iterative interventions, followed by postoperative structured, sustained (often for life-time) rehabilitation are essential for obtaining functional results. Adequate prophylaxis of complications represents a main therapeutic objective, as well. Key words: traumatic brain injury (TBI), spinal cord injury (SCI), vegetative status, spasticity, contracture, capsulotomy, orthopaedic surgery, neurorehabilitation

Talectomy for equinovarus deformity in family members with hereditary motor and sensory neuropathy type I

The treatment of severe rigid neurogenic clubfoot deformities still remains a challenging problem in modern paediatric orthopaedics. In those cases, in spite of being a palliative procedure, talectomy has been advocated for the correction of the deformity thus providing a stable plantigrade foot which allows pain-free walking with standard footwear. Herein, we present the results after talectomy in two patients (brother and sister) affected by a hereditary motor and sensory neuropathy type I, with rigid severe pes equinovarus deformities.

The management of osteoarthritis in movement disorders: a case discussion

BACKGROUND

A 37-year-old female with a hyperkinetic movement disorder due to chorea-acanthocytosis developed severe painful degenerative arthritis of her left knee as a consequence of repetitive involuntary flexion and extension dystonic and ballistic movements.

CASE REPORT

Despite profound limitation in her mobility a total knee replacement was successfully undertaken.

DISCUSSION

The case emphasizes that patients with progressive neurodegenerative disorders may derive relief or resolution of pain by joint replacement even if mobility does not improve following surgery. A multidisciplinary approach to care is essential.

Painful pes planovalgus: an uncommon pediatric orthopedic presentation of Charcot-Marie-Tooth disease

Charcot-Marie-Tooth (CMT) disease is an inherited progressive neurologic disorder often diagnosed by the characteristic cavovarus feet. In the pediatric population, the presentation is often more variable and age dependent. Pediatric orthopedic surgeons may be referred patients for the evaluation of musculoskeletal symptoms that may be consistent with early CMT, but because of the lack of the surgeon's familiarity, the diagnosis may be delayed or missed. We present three patients with pes planovalgus who were found to have CMT and review the recent literature relevant to the pediatric orthopedic surgeon. The clinical summary is given for three patients who presented to the orthopedic surgery department for lower extremity symptoms and were eventually diagnosed with CMT. A literature search was performed and information valuable for a pediatric orthopedic surgeon to consider is summarized. Foot morphology in most young children with CMT initially is pes planovalgus, with the minority being pes cavovarus. As the child grows, the proportion changes to become nearly entirely cavus or cavovarus, with very few remaining planovalgus or planus. Unexplained regional pain may also be suggestive of CMT. Whereas CMT often presents initially in adolescent or adult patients with cavovarus feet, thin calves, or a high-stepping gait, pediatric presentation is not so consistent. Young children with CMT often have pes planovalgus. There are even some variants of CMT where patients still may present with severe pes planovalgus into late adolescence. We recommend that pediatric orthopedic surgeons consider CMT even in patients who do not have cavus or cavovarus feet, especially in the context of unexplained regional pain of the lower extremities. Patients should be referred to a pediatric neurologist for definitive diagnosis and management, with the orthopedic surgeon remaining involved for specific procedures.

Total hip replacement in patients with neurological conditions

Neurological conditions affecting the hip pose a considerable challenge in replacement surgery since poor and imbalanced muscle tone predisposes to dislocation and loosening. Consequently, total hip replacement (THR) is rarely performed in such patients. In a systematic review of the literature concerning THR in neurological conditions, we found only 13 studies which described the outcome. We have reviewed the evidence and discussed the technical challenges of this procedure in patients with cerebral palsy, Parkinson’s disease, poliomyelitis and following a cerebrovascular accident, spinal injury or development of a Charcot joint. Contrary to traditional perceptions, THR can give a good outcome in these often severly disabled patients.