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Cain M, Lemhouse P, Buckon C, Freese KP. Pediatric Spastic Wrist Contractures Can Be Well Managed With Wrist Arthrodesis. J Pediatr Orthop 2024; 44:333-339. [PMID: 38450641 DOI: 10.1097/bpo.0000000000002648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
BACKGROUND Severe spastic wrist contractures secondary to cerebral palsy (CP) or alike can have significant implications for patient hand function, hygiene, skin breakdown, and cosmesis. When these contractures become rigid, soft tissue procedures alone are unable to obtain or maintain the desired correction. In these patients' wrist arthrodesis is an option-enabling the hand to be stabilized in a more functional position for hygiene, dressing, and general cosmesis, though are patients satisfied? METHODS All children who had undergone a wrist arthrodesis for the management of a severe wrist contracture at Shriners Hospital, Portland between January 2016 and January 2021 were identified (n=23). A chart review was undertaken to obtain data-demographic, operative, clinical, and radiographic. All patients were then contacted to participate in 2 patient-reported outcome questionnaires (74% response agreement), a numerical rating scale (NRS), based on the visual analog scale (VAS) and the disability analog scale (DAS). Results were assessed with the aid of descriptive statistics, means and percentages with the primary focus of determining overall patient satisfaction with the procedure. RESULTS Twenty-three patients were included in the review, and 74% took part in the prospective survey. Included were 10 patients with hemiplegia, 4 with triplegia, 7 with quadriplegia, 1 with a diagnosis of Rhett syndrome, and 1 with a history of traumatic brain injury. All patients achieved radiologic union by a mean of 8 weeks, and 87% obtained a neutral postoperative wrist alignment. The NRS showed 88% of patients were highly satisfied with their results; specifically, 82% had an improved appearance, 53% improved function, 71% improved daily cares, and 65% improved hygiene. The postoperative DAS score averaged 4.7 of 12 indicating mild disability. When looking at how a patient's diagnostic subtype affected outcome results, patients with triplegia reported less improvement and greater disability on the NRS and DAS, averaging 9.5 (severe disability on the DAS). The GMFCS classification had less correlation with outcomes. CONCLUSION Wrist arthrodesis is a good option for the management of pediatric spastic wrist contractures, with limited complications and an overall high patient/carer satisfaction rate. LEVEL OF EVIDENCE Level IV-case series.
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Affiliation(s)
- Megan Cain
- Shriners Children's-Portland, Portland, OR
- Lyell McEwin Hospital, Elizabeth Vale
- The University of Adelaide, Adelaide, South Australia, Australia
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2
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Nixon M, Zreik N, Bakhit H. Wrist arthrodesis and soft tissue rebalancing in the spastic hand. J Hand Surg Eur Vol 2024; 49:420-427. [PMID: 37879641 DOI: 10.1177/17531934231205548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
The aim of the present study was to investigate the outcomes of wrist arthrodesis with simultaneous soft tissue rebalancing of the digits in the spastic wrist. In 43 wrists (40 patients) the surgical goals, patient selection, procedures and outcomes were assessed. Preoperatively, mean passive extension was to 44° below neutral and only two patients had volitional control. Postoperatively, 33 and 10 cases reported excellent and good outcomes, respectively. A mean Goal Attainment Score of 62.4 indicated better than expected outcomes. In total, 37 hands required simultaneous finger rebalancing: 24 underwent tendon transfers and 13 surgical releases. A total of 12 thumbs required tendon transfers, three soft tissue releases and five metacarpophalangeal joint stabilization. Ten patients experienced complications, most commonly wound problems and implant failure, predominantly observed in patients with severe wrist and elbow contractures. In conclusion, wrist arthrodesis with simultaneous soft tissue rebalancing of the digits offers a viable approach in patients with severe spasticity. Cautious patient selection and consideration of potential complications are crucial for good outcomes.Level of evidence: IV.
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Affiliation(s)
- Matthew Nixon
- Countess of Chester Hospital, Chester, UK
- Royal Manchester Royal Children's Hospital, Manchester, UK
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3
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Fitoussi F, Lallemant-Dudek P. The upper limb in children with cerebral palsy. Evaluation and treatment. Orthop Traumatol Surg Res 2024; 110:103763. [PMID: 37992866 DOI: 10.1016/j.otsr.2023.103763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 11/24/2023]
Abstract
Management of the upper limb in children with cerebral palsy is often complex and must be carried out by a team experienced in this field. Several clinical parameters must be taken into consideration, such as higher functions, visual problems, overall upper limb function, motor control, sensitivity, presence of hemineglect or synkinesis, limb position at rest and during walking. And last but not least, a complete analysis of the upper limb is required. It is only after this exhaustive assessment - which often includes occupational therapy, physiotherapy and in some cases, video and electromyography evaluations - that a treatment indication can be discussed with the patient's family. Other than baseline treatment consisting of rehabilitation, occupational therapy and bracing, botulinum toxin injections could be an option, targeting specific muscle groups. Surgical treatments, which are often indicated in severe forms with contractures, are proposed after the patient's case is presented at a multidisciplinary meeting. These include selective neurotomy, muscle-tendon release, transfer or lengthening, and procedures on bone and joints (osteotomy, arthrodesis). LEVEL OF EVIDENCE: Expert opinion.
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Affiliation(s)
- Frank Fitoussi
- Armand Trousseau Hospital - Sorbonne Medical University, Paris, France.
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4
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Bamal R, Sultan R, Cappuyns L, Hassan Z, McArthur P. Use of volar distal radius plate dorsally for wrist arthrodesis in patients with upper limb spasticity: A retrospective review. J Plast Reconstr Aesthet Surg 2023; 83:318-325. [PMID: 37295156 DOI: 10.1016/j.bjps.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 10/16/2022] [Accepted: 05/02/2023] [Indexed: 06/12/2023]
Abstract
Standard wrist arthrodesis implants are generally designed for adult joints with arthritis. They are often too big for patients with limb spasticity who generally tend to have osteopenic and smaller bones for their age, resulting in high complication rates. We previously described the novel use of volar distal radius variable-angle locking plate (APTUS® Wrist distal radius system 2.5, Medartis AG, Basel, Switzerland) on the dorsum for wrist arthrodesis in patients with limb spasticity. This study aimed to further establish the use of the implant by reporting the outcomes in cohort A (nondistal radius plate) and cohort B (distal radius plate cohort). Patient-reported outcome measures were used to assess the primary outcome, whereas secondary outcomes included implant-related complications and improvement in wrist position and fusion rates. A total of 17 wrist arthrodesis procedures were performed over a period of 4 years in 15 patients for wrist deformity secondary to limb spasticity. There were no complaints of implant prominence, implant or tendon irritation, metacarpal prominence, or extension requiring further treatment in cohort B. Cohort A had a high implant removal rate that is comparable to the published literature. Both groups reported significant improvement in hygiene and wrist position but neither group had any appreciable gain in function. Volar distal radius variable-angle locking plates appear to be safe and have superior patient acceptability and low complication rates when used dorsally for wrist arthrodesis in patients with upper limb spasticity. Comparable overall satisfaction rates in cohort B were reported in relation to the literature and the cohort A in this study.
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Affiliation(s)
- Rahul Bamal
- Department of Plastic Surgery, Whiston Hospital, Prescot L35 5DR, UK; Department of Plastic Surgery, Alder Hey Children's Hospital, Liverpool L15 5AB, UK; School of Medicine & Dentistry, Griffith University, Gold Coast, Queensland, Australia.
| | - Ramy Sultan
- Department of Plastic Surgery, Whiston Hospital, Prescot L35 5DR, UK
| | - Laura Cappuyns
- Department of Plastic Surgery, Whiston Hospital, Prescot L35 5DR, UK
| | - Zahid Hassan
- Department of Plastic Surgery, Whiston Hospital, Prescot L35 5DR, UK; Department of Plastic Surgery, Alder Hey Children's Hospital, Liverpool L15 5AB, UK
| | - Paul McArthur
- Department of Plastic Surgery, Whiston Hospital, Prescot L35 5DR, UK; Department of Plastic Surgery, Alder Hey Children's Hospital, Liverpool L15 5AB, UK
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5
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Padgett AM, Howie CM, Sanchez TC, Cimino A, Williams KA, Gilbert SR, Conklin MJ. Pediatric fractures following implant removal: A systematic review. J Child Orthop 2022; 16:488-497. [PMID: 36483642 PMCID: PMC9723876 DOI: 10.1177/18632521221138376] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 10/26/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To evaluate the available literature for postoperative fracture rates following implant removal in the pediatric population. METHODS A systematic review of articles in the PubMed and Embase computerized literature databases from January 2000 to June 2022 was performed using PRISMA guidelines. Randomized controlled trials, case-control studies, cohort studies (retrospective and prospective), and case series involving pediatric patients that included data on fracture rate following removal of orthopedic implants were eligible for review. Two authors independently extracted data from selected studies for predefined data fields for implant type, anatomic location of the implant, indication for implantation, fracture or refracture rate following implant removal, mean time to implant removal, and mean follow-up time. RESULTS Fifteen studies were included for qualitative synthesis. Reported fracture rates following implant removal vary based on several factors, with an overall reported incidence of 0%-14.9%. The available literature did not offer sufficient data for conduction of a meta-analysis. CONCLUSION Our systematic review demonstrates that fracture following implant removal in pediatric patients is a relatively frequent complication. In children, the forearm and femur are the most commonly reported sites of fracture following removal of implants. Traumatic fractures treated definitively with external fixation have the highest reported aggregate rate of refracture. Knowledge of the incidence of this risk is important for orthopedic surgeons. There remains a need for well-designed studies and trials to further clarify the roles of the variables that contribute to this complication.
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Affiliation(s)
- Anthony M Padgett
- Department of Orthopaedic Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA,Anthony M Padgett, Department of Orthopaedic Surgery, The University of Alabama at Birmingham, Lowder Building, Ste. 316, 1600 7th Ave. South, Birmingham, AL 35233, USA.
| | - Cole M Howie
- Department of Orthopaedic Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Thomas C Sanchez
- Department of Orthopaedic Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Addison Cimino
- Department of Orthopaedic Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kevin A Williams
- Department of Orthopaedic Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA,Division of Orthopedic Surgery, Children’s of Alabama, Birmingham, AL, USA
| | - Shawn R Gilbert
- Department of Orthopaedic Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA,Division of Orthopedic Surgery, Children’s of Alabama, Birmingham, AL, USA
| | - Michael J Conklin
- Department of Orthopaedic Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA,Division of Orthopedic Surgery, Children’s of Alabama, Birmingham, AL, USA
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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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7
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Gross R, Verduzco-Gutierrez M, Draulans N, Zimerman M, Francisco G, Deltombe T. Module 3: Surgical management of spasticity. THE JOURNAL OF THE INTERNATIONAL SOCIETY OF PHYSICAL AND REHABILITATION MEDICINE 2022. [DOI: 10.4103/2349-7904.347809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Wrist shortening arthrodesis with volar plate in a dorsal position for spastic wrist contracture. HAND SURGERY & REHABILITATION 2021; 41:42-47. [PMID: 34688950 DOI: 10.1016/j.hansur.2021.10.313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/15/2021] [Accepted: 10/18/2021] [Indexed: 10/20/2022]
Abstract
Total wrist arthrodesis in severe wrist flexion deformities (greater than 60°) due to spasticity represents a valid therapeutic option. It aims to improve the hand's appearance, hygiene, function and to prevent the deformity from getting worse. The objective of this study is to evaluate the clinical and anatomical results of wrist shortening arthrodesis using a classic volar plate in the dorsal position in functional surgery for central spastic hands. We conducted a single-center analysis of a series of patients who underwent this shortening arthrodesis. The review at a minimum 1-year follow-up included a clinical evaluation (House score, INOM score, patient satisfaction and complications), and anatomical evaluation (arthrodesis position, bone healing and carpometacarpal arthropathy). Twenty-eight patients with a mean age of 40.6 years (18-74) were included at a mean follow-up of 30.6 months (12-75). The fusion rate was 100%. No carpometacarpal arthropathy was noted. The mean position of the fused wrist was 11° extension and 15° ulnar tilt. There were two complications (7%): one postoperative hematoma and one case of discomfort due to impingement that required plate removal. The House score was significantly improved postoperatively (2.4 (0-5) versus 1.8 (0-4), p < 0.001), as was the INOM score (45 (12-64) versus 63 (36-84), p < 0.001). The patient satisfaction rate was 93%. The use of a simple and common material (volar plate in dorsal position) during this challenging surgery (spastic wrist contracture), provides good anatomical results and high patient satisfaction. LEVEL OF EVIDENCE: Level 4, case series, therapeutic study.
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Singh G, Singh V, Ahmad S, Kalia RB, Arora SS, Dubey S. A prospective study on transfer of pronator teres to extensor carpi radialis brevis for forearm and wrist deformity in children with cerebral palsy. J Hand Surg Eur Vol 2021; 46:247-252. [PMID: 32990136 DOI: 10.1177/1753193420960330] [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] [Indexed: 02/03/2023]
Abstract
We prospectively evaluated the clinical and functional outcomes of pronator teres to extensor carpi radialis brevis transfer in children with cerebral palsy. Patients were followed-up at 6 months postoperatively, and functionally assessed using the House classification, Manual Ability Classification System (MACS) and Upper Extremity Functional Index (UEFI). Fifteen children with a mean age of 8.1 years underwent tendon transfers. All patients were of Gschwind and Tonkin Grade 2 for pronation deformity; eight patients were of Zancolli's classification Group 1 and seven, Group 2 for wrist flexion deformity. The average gain in active supination was 67°, and wrist extension 15°. An increase of 7.0 in the UEFI score was recorded, although no significant improvement in MACS and House classification was observed. We conclude that the pronator teres to extensor carpi radialis brevis transfer improves upper limb function through effective correction of forearm pronation and wrist flexion deformities.Level of evidence: II.
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Affiliation(s)
- Gobinder Singh
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Vivek Singh
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Sabeel Ahmad
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - R B Kalia
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Shobha S Arora
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Siddharth Dubey
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
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Vergara-Amador E, Franco-Chaparro L. Wrist Arthrodesis in Children With Cerebral Palsy. Tech Hand Up Extrem Surg 2020; 24:155-158. [PMID: 32349096 DOI: 10.1097/bth.0000000000000288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Wrist treatment in spastic cerebral palsy includes splints, botulinum toxin, tendon transfers, tendon lengthening, capsular liberations, and arthrodesis. A well-indicated wrist arthrodesis corrects deformity improving function and cosmetic appearance in patients with fixed deformities. It is indicated in patients with cerebral palsy, older than 12 years with a fixed deformity in wrist flexion. We report 11 clinical cases with the wrist arthrodesis with a plate of 3.5 with 2.7 mm by dorsal approach and technical resources to minimize the complications of tendon irritation and dorsal discomfort. We present an illustrative clinical case. It is a known procedure, its execution must be careful to avoid complications.
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Affiliation(s)
- Enrique Vergara-Amador
- Orthopedic and Traumatology Speciality, Hand Surgery, Medicine Faculty, National University of Colombia
| | - Lina Franco-Chaparro
- Hand surgery Fellowship, University Foundation of Health Sciences, Bogotá, Colombia
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11
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Boulahouache A, Cambon-Binder A, Chouiha M, Lardjane ML, Belkheyar Z. Chondrodesis of the wrist in children with severe paralytic hand deformities. HAND SURGERY & REHABILITATION 2020; 39:251-255. [PMID: 32244070 DOI: 10.1016/j.hansur.2020.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 02/13/2020] [Accepted: 02/18/2020] [Indexed: 10/24/2022]
Abstract
We examined the anatomical and clinical results of a new wrist subphyseal arthrodesis method called chondrodesis, which relies on resorbable suture-bone fixation for children with severe paralytic hand deformities and does not require fixation devices or bone grafting. Four children's wrists underwent the procedure, resulting in three successful wrist bone fusions. The wrists were stabilized by joint fusion in 4-5 months in good positions, ranging from neutral to extension 15°, while still allowing the forearm to keep growing since the radial growth plate remained open as of the last follow-up. The procedure improved hand function (House score, Raimondi score) and appearance. It also increased control over gripping motions with the operated hand, and even restored key pinch ability in one of the patients. The youngest patient was not able to achieve bone fusion at the key sites and will need further corrective procedures at a later and more optimal age. This novel procedure is appealing because of its technical reproducibility, low cost, encouraging outcomes, ease of rehabilitation, and because it spares the physeal cartilage.
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Affiliation(s)
- A Boulahouache
- Orthopedic clinic, hand surgery, Cité 280 Logts-Draa el bordjBt17, 10000 Bouira, Algeria.
| | - A Cambon-Binder
- Service de chirurgie orthopédique et traumatologique - SOS main, Hôpital Saint-Antoine, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France.
| | - M Chouiha
- Cité Hachi Abderrahmane 160/20, 17000 Djelfa, Algeria.
| | - M-L Lardjane
- 19, rue Berouaken, Boudouaou, 35000 Boumerdes, Algeria.
| | - Z Belkheyar
- 8-10, rue de la Folie-Regnault, 75011 Paris, France.
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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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13
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Abstract
Although individual pediatric hand problems are rare, the combined burden of congenital anomalies, neuromuscular disease, and trauma is considerable in low-resource environments where treatment is unavailable. Surgeons from high-income countries respond to the need for care with short-term trips to low-resource environments to operate and teach local surgeons. Hand problems are amenable to this model, because they may be disabling and treatable with low-risk, low-resource surgery. Pediatric hand problems are especially compelling, because growth may adversely affect outcomes, and resulting disability is lifelong. This article addresses considerations for treating children's hands in low-resource environments, and approaches to specific conditions.
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14
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Maltais DB, Ferland C, Perron M, Roy JS. Reliability of Inclinometer-Derived Passive Range of Motion Measures in Youth with Cerebral Palsy. Phys Occup Ther Pediatr 2019; 39:655-668. [PMID: 31144588 DOI: 10.1080/01942638.2019.1597822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Aims: This study evaluated, for youth with cerebral palsy (CP), the reliability of passive range of motion (PROM) measures taken with an inclinometer, a device that may be simpler to use than a goniometer. Methods: The PROM for elbow and wrist extension, ankle dorsal flexion (knee flexed 90° and fully extended), and the knee popliteal angle of 30 youth with CP (18 boys, 12 girls, 7.0 ± 3.8 years old, classified in Gross Motor Function Classification levels I-V) was measured using an inclinometer. Two physical therapists took the measures during two different sessions, a maximum of 1 week apart. Results: Good mean intra-rater inter-session, inter-rater intra-session, and inter-rater inter-session reliability (ICC = 0.75-0.89), was found for the elbow, ankle, and knee sites. Absolute reliability for these sites and conditions was 7-14° (90% confident) and 10-16° (95% confident). Reliability values for wrist extension were comparable, albeit slight lower. Conclusions: Similar to published values for goniometry, inclinometery yields reliable upper and lower limb PROM measures from ambulatory and non-ambulatory youth with CP whether measures are carried out by different evaluators within or across sessions or whether measures are performed by the same evaluator across sessions.
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Affiliation(s)
- Désirée B Maltais
- Department of Rehabilitation, Laval University , Quebec City , Quebec , Canada.,Centre for Interdisciplinary Research in Rehabilitation and Social Integration , Quebec City , Quebec , Canada
| | - Chantal Ferland
- Centre Integre Universitaire de Santé et de Services Sociaux de la Capitale-Nationale , Quebec City , Quebec , Canada
| | - Marc Perron
- Centre Integre Universitaire de Santé et de Services Sociaux de la Capitale-Nationale , Quebec City , Quebec , Canada
| | - Jean-Sébastien Roy
- Department of Rehabilitation, Laval University , Quebec City , Quebec , Canada.,Centre for Interdisciplinary Research in Rehabilitation and Social Integration , Quebec City , Quebec , Canada
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15
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Abstract
Upper extremity spasticity may result from a variety of types of brain injury, including cerebral palsy, stroke, or traumatic brain injury. These conditions lead to a predictable pattern of forearm and wrist deformities caused by opposing spasticity and flaccid paralysis. Upper extremity spasticity affects all ages and sociodemographics and is a complex clinical problem with a variety of treatment options depending on the patient, the underlying disease process, and postoperative expectations. This article discusses the cause, diagnosis, operative planning, operative techniques, postoperative outcomes, and rehabilitation protocols for the spastic wrist and forearm.
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Affiliation(s)
- Stephen P Duquette
- Division of Plastic Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall 232, Indianapolis, IN 46202, USA
| | - Joshua M Adkinson
- Division of Plastic Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall 232, Indianapolis, IN 46202, USA.
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16
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Genêt F, Denormandie P, Keenan MA. Orthopaedic surgery for patients with central nervous system lesions: Concepts and techniques. Ann Phys Rehabil Med 2018; 62:225-233. [PMID: 30290282 DOI: 10.1016/j.rehab.2018.09.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 09/09/2018] [Accepted: 09/09/2018] [Indexed: 12/26/2022]
Abstract
Since ancient times, the aim of orthopedic surgery has been to correct limb and joint deformities, including those resulting from central nervous system lesions. Recent developments in the treatment of spasticity have led to changes in concepts and management strategies. The increase in life expectancy has increased the functional needs of patients. Orthopedic surgery, along with treatments for spasticity, improves the functional capacity of patients with neuro-orthopaedic disorders, improving their autonomy. In this paper, we describe key moments in the history of orthopedic surgery regarding the treatment of patients with central nervous system lesions, from poliomyelitis to stroke-related hemiplegia, from the limbs to the spine, and from contractures to heterotopic ossification. A synthesis of the current surgical techniques is then provided, and the importance of multidisciplinary evaluation and management is highlighted, along with indications for medical, rehabilitation and surgical treatments and their combinations. We explain why it is essential to consider patients' expectations and to set achievable goals, particularly before surgery, which is by nature irreversible. More recently, specialized surgical teams have begun to favor the use of soft-tissue techniques over bony and joint procedures, except for spinal disorders. We highlight that orthopedic surgery is no longer the end-point of treatment. For example, lengthening a contractured muscle improves the balance around a joint, improving mobility and stability but may be only part of the problem. Further medical treatment and rehabilitation, or additional surgery, are often necessary to continue to improve the function of the limb. Despite the recognized effectiveness of orthopedic surgery for neuro-orthopedic disorders, few studies have formally evaluated them. Hence, there is a need for research to provide evidence to support orthopedic surgery for treating neuro-orthopedic disorders.
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Affiliation(s)
- F Genêt
- Service de médecine physique et de réadaptation, hôpital Raymond Poincaré, Assistance publique-Hôpitaux de Paris, CIC-IT 1429, 92380 Garches, France; End:icap" U1179 Inserm, service de université Versailles Saint Quentin en Yvelines, UFR des Sciences de la Santé-Simone Veil, 2, avenue de la source de bièvres, 78170 Montigny le Bretonneux, France.
| | - P Denormandie
- End:icap" U1179 Inserm, service de université Versailles Saint Quentin en Yvelines, UFR des Sciences de la Santé-Simone Veil, 2, avenue de la source de bièvres, 78170 Montigny le Bretonneux, France; Chirurgie orthopédique et traumatologique, hôpital Raymond Poincaré, Assistance publique-Hôpitaux de Paris, CIC-IT 1429, 92380 Garches, France
| | - M A Keenan
- Penn Neuro-Orthopaedics Service, University of Pennsylvania, Philadelphia, PA, USA
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Louwers A, Warnink-Kavelaars J, Obdeijn M, Kreulen M, Nollet F, Beelen A. Effects of Upper-Extremity Surgery on Manual Performance of Children and Adolescents with Cerebral Palsy: A Multidisciplinary Approach Using Shared Decision-Making. J Bone Joint Surg Am 2018; 100:1416-1422. [PMID: 30106823 DOI: 10.2106/jbjs.17.01382] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Little is known about the effects of upper-extremity surgery on the manual performance of children and adolescents with cerebral palsy (CP). This clinical cohort study describes our experience with patient selection based on multidisciplinary assessment and shared decision-making and the effects of upper-extremity surgery on manual performance and patient-relevant outcomes. METHODS All patients (up to 20 years of age) with CP referred to our multidisciplinary team for evaluation for upper-extremity surgery between July 2011 and May 2017 were included. Suitability for upper-extremity surgery was assessed with comprehensive, multidisciplinary screening, and the decision to proceed with surgery was made together with the patient. Individual patient-relevant goals were identified with the Canadian Occupational Performance Measure (COPM); perceived independence in performing bimanual activities at home was assessed with the ABILHAND-Kids tool, and perceived quality of use of the affected hand during daily activities was assessed with a visual analog scale (VAS). The quality of use of the affected hand during bimanual performance was measured with the Assisting Hand Assessment (AHA), and gross manual dexterity was evaluated with the Box and Block Test (BBT). All baseline assessments were repeated at an average of 9 months after the surgery. RESULTS Of 66 patients assessed by the multidisciplinary upper-extremity-surgery team, 44 were considered eligible for upper-extremity surgery. Of these patients, 39 (mean age and standard deviation [SD], 14.9 ± 2.10 years, 87% with unilateral CP, and 72% at Manual Ability Classification System [MACS] level II) underwent upper-extremity surgery and were evaluated in the pre-post study. All outcomes improved significantly after upper-extremity surgery, with average improvements of 3.1 ± 1.6 points in the COPM-Performance (COPM-P) score (p < 0.001), 3.3 ± 2.1 points in the COPM-Satisfaction (COPM-S) score (p < 0.001), 1.5 ± 1.2 logits in the ABILHAND score (p < 0.001), 2.4 ± 1.9 cm in the VAS score (p < 0.001), 6.7 ± 4.2 units in the AHA score (p < 0.001), and 2.2 ± 5.0 blocks/minute on the BBT (p = 0.021). The improvement in the COPM-P, COPM-S, ABILHAND, VAS, AHA, and BBT scores was clinically meaningful in 80%, 77%, 55%, 62%, 71%, and 31% of the patients, respectively. CONCLUSIONS Careful assessment of eligibility for upper-extremity surgery, based on multidisciplinary screening and shared decision-making, resulted in a clinically relevant improvement in patient-specific functional and/or cosmetic goals and manual performance after upper-extremity surgery in most patients with CP. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Annoek Louwers
- Departments of Rehabilitation (A.L., J.W.-K., F.N., and A.B.) and Plastic, Reconstructive and Hand Surgery (M.O. and M.K.), Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Jessica Warnink-Kavelaars
- Departments of Rehabilitation (A.L., J.W.-K., F.N., and A.B.) and Plastic, Reconstructive and Hand Surgery (M.O. and M.K.), Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Miryam Obdeijn
- Departments of Rehabilitation (A.L., J.W.-K., F.N., and A.B.) and Plastic, Reconstructive and Hand Surgery (M.O. and M.K.), Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Mick Kreulen
- Departments of Rehabilitation (A.L., J.W.-K., F.N., and A.B.) and Plastic, Reconstructive and Hand Surgery (M.O. and M.K.), Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands.,Department of Hand Surgery, Rode Kruis Ziekenhuis, Beverwijk, the Netherlands
| | - Frans Nollet
- Departments of Rehabilitation (A.L., J.W.-K., F.N., and A.B.) and Plastic, Reconstructive and Hand Surgery (M.O. and M.K.), Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Anita Beelen
- Departments of Rehabilitation (A.L., J.W.-K., F.N., and A.B.) and Plastic, Reconstructive and Hand Surgery (M.O. and M.K.), Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
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