Quality management, quality assurance, and quality control in medical physics

The historic and ongoing evolution of the practice, technology, terminology, and implementation of programs related to quality in the medical radiological professions has given rise to the interchangeable use of the terms Quality Management (QM), Quality Assurance (QA), and Quality Control (QC) in the vernacular. This White Paper aims to provide clarification of QM, QA, and QC in medical physics context and guidance on how to use these terms appropriately in American College of Radiology (ACR) Practice Parameters and Technical Standards, generalizable to other guidance initiatives. The clarification of these nuanced terms in the radiology, radiation oncology, and nuclear medicine environments will not only boost the comprehensibility and usability of the Medical Physics Technical Standards and Practice Parameters, but also provide clarity and a foundation for ACR's clinical, physician-led Practice Parameters, which also use these important terms for monitoring equipment performance for safety and quality. Further, this will support the ongoing development of the professional practice of clinical medical physics by providing a common framework that distinguishes the various types of responsibilities borne by medical physicists and others in the medical radiological environment. Examples are provided of how QM, QA, and QC may be applied in the context of ACR Practice Parameters and Technical Standards.

Orthopaedic surgery for patients with central nervous system lesions: Concepts and techniques

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.

Histopathology of periarticular non-hereditary heterotopic ossification

In the mature adult skeleton, new bone formation is normally restricted to regeneration of osseous tissue at sites of fracture. However, heterotopic ossification, or the formation of bone outside the normal skeleton, can occur within muscle, adipose, or fibrous connective tissue. Periarticular non-hereditary heterotopic ossification (NHHO) may occur after musculoskeletal trauma, following CNS injury, with certain arthropathies, or following injury or surgery that is often sustained in the context of age-related pathology. The histological mechanism of bone development in these forms of heterotopic ossification has thus far been uncharacterized. We performed a histological analysis of 90 bone specimens from 18 patients with NHHO secondary to defined precipitating conditions, including traumatic brain injury, spinal cord injury, cerebrovascular accident, trauma without neurologic injury, and total hip or knee arthroplasty. All bone specimens revealed normal endochondral osteogenesis at heterotopic sites. We defined the order of sequence progression in NHHO lesion formation as occurring through six distinct histological stages: (1) perivascular lymphocytic infiltration, (2) lymphocytic migration into soft tissue, (3) reactive fibroproliferation, (4) neovascularity, (5) cartilage formation, and (6) endochondral bone formation. This study provides the first systematic evaluation of the predominant histopathological findings associated with multiple forms of NHHO and shows that they share a common mechanism of lesion formation.

Circulating osteogentic precursor cells in non-hereditary heterotopic ossification

Non-hereditary heterotopic ossification (NHHO) may occur after musculoskeletal trauma, central nervous system (CNS) injury, or surgery. We previously described circulating osteogenic precursor (COP) cells as a bone marrow-derived type 1 collagen⁺CD45⁺subpopulation of mononuclear adherent cells that are able of producing extraskeletal ossification in a murine in vivo implantation assay. In the current study, we performed a tissue analysis of COP cells in NHHO secondary to defined conditions, including traumatic brain injury, spinal cord injury, cerebrovascular accident, trauma without neurologic injury, and joint arthroplasty. All bone specimens revealed the presence of COP cells at 2-14 cells per high power field. COP cells were localized to early fibroproliferative and neovascular lesions of NHHO with evidence for their circulatory status supported by their presence near blood vessels in examined lesions. This study provides the first systematic evaluation of COP cells as a contributory histopathological finding associated with multiple forms of NHHO. These data support that circulating, hematopoietic-derived cells with osteogenic potential can seed inflammatory sites, such as those subject to soft tissue injury, and due to their migratory nature, may likely be involved in seeding sites distant to CNS injury.

Orthopedic evaluation and surgical treatment of the spastic shoulder

The spastic shoulder can often result from brain injury that causes disruption in the upper motor neuron inhibitory pathways. Patients develop dyssynergic muscle activation, muscle weakness, and contractures and often present with fixed adduction and internal rotation deformity to the limb. This article reviews the importance of a comprehensive preoperative evaluation and discusses appropriate treatment strategies based on preoperative evaluation.

Clinical results of the excision of heterotopic bone around the elbow: a systematic review

BACKGROUND

Heterotopic ossification (HO) of the elbow can occur following direct trauma, brain injury, or burns. Development of elbow HO is sporadic, making levels 1-3 clinical evidence difficult to establish. We systematically reviewed literature regarding management and outcomes of surgically treated elbow HO.

METHODS

A systematic review of the literature regarding elbow HO was performed to compare imaging modalities, surgical timing, surgical approaches, and methods of prophylaxis in outcomes of patients treated with excision.

RESULTS

Our systematic review included 24 level 3 or 4 studies investigating 384 post-trauma (158), brain injury (105), or burn (94) patients with elbows complicated by HO that were treated with surgical excision. Average patient age was 36.9 years and there was a 65/35 M/F ratio. For all etiologies, preoperatively elbow flexion/extension averaged 53/83; postoperatively elbow flexion/extension significantly improved to 22/123. Regardless of the etiology, surgical excision of elbow HO significantly improved functional range of motion. Neither total body surface area (TBSA) burned for burn patients or Garland classification for brain-injured patients correlated with outcome. Overall complication rate was 22.6% and included HO recurrence (11.9%), ulnar nerve injury, infection, and delayed wound healing.

CONCLUSION

Surgical treatment of elbow HO leads to improved functional outcome, whether the etiology of bone formation was direct elbow trauma, brain injury, or thermal injury.

Myotendinous lengthening of the elbow flexor muscles to improve active motion in patients with elbow spasticity following brain injury

BACKGROUND

The objective of this study was to evaluate the outcomes of a novel technique of fractional myotendinous lengthening of the elbow flexors in patients with volitional motor control and spastic elbow flexion deformities after brain injury.

METHODS

A retrospective review of 42 consecutive patients with spastic elbow flexion deformities and upper motor neuron (UMN) syndrome was performed. Each patient had volitional motor control but limited elbow extension and underwent myotendinous lengthening of the elbow flexor muscles. Outcome measures included pre and post-operative active and passive arc of motion, Modified Ashworth Scale (MAS) of spasticity, and complications.

RESULTS

There were 26 men and 16 women. The etiologies of UMN syndrome were stroke (30 patients), traumatic brain injury (11 patients), and cerebral palsy (1 patient). Average duration between injury and surgery was 6.6 years. At an average follow-up of 14 months, improvements were noted in active extension (42° to 20°; P < .001). In addition, active arc of motion increased from 77° (range of motion [ROM]: 42° to 119°) to 113° (ROM: 20° to 133°) (P < .001) and passive arc of motion increased from 103° (ROM: 24°-127°) to 131° (ROM: 8°-139°) (P < .001). Significant improvement in MAS was also noted after surgery (2.7 to 1.9; P < .001). Superficial wound dehiscence occurred in 2 patients and was successfully treated nonoperatively.

CONCLUSION

In patients with spastic elbow flexion deformities and active motor control, fractional myotendinous lengthening of the elbow flexors safely improves active extension and the overall arc of motion while affording immediate postoperative elbow motion.

LEVEL OF EVIDENCE

Level IV, Case Series, Treatment Study.

Muscle releases to improve passive motion and relieve pain in patients with spastic hemiplegia and elbow flexion contractures

INTRODUCTION

Patients with spastic hemiplegia after upper motor neuron (UMN) injury can develop elbow contractures. This study evaluated outcomes of elbow releases in treating spastic elbow flexion contractures in hemiplegic patients.

METHODS

Adults with spastic hemiplegia due to UMN injury who underwent elbow releases (brachialis, brachioradialis, and biceps muscles) were included. Nonoperative treatment was unsuccessful in all patients. Patients complained of difficulty with passive functions. Passive range of motion (ROM), pain relief, Modified Ashworth spasticity score, and complications were evaluated preoperatively and postoperatively.

RESULTS

There were 8 men and 21 women with an average age of 52.4 years (range, 24.1-81.4 years). Seventeen patients had pain preoperatively. Postoperative follow-up was a mean of 1.7 years (range, 1-4.5 years). Preoperatively, patients lacked a mean of 78° of passive elbow extension compared with 17° postoperatively (P < .001). The Modified Ashworth spasticity score improved from 3.3 to 1.4 (P = .001). All patients with preoperative pain had improved pain relief, and 16 (94%) were pain-free. There were 3 wound complications that resolved nonsurgically and 1 recurrence. Age, sex, etiology, and chronicity of UMN injury were not associated with improvement in motion or pain relief (P > .05).

CONCLUSION

Releases of the brachialis, brachioradialis, and biceps muscles can be an effective means of pain relief, improved passive ROM, and decreased spasticity in patients with elbow flexion deformity after UMN injury.

Factors affecting interest in orthopedics among female medical students: a prospective analysis

The field of orthopedics has a limited ability to recruit high-quality female applicants. The purpose of this study was to determine whether early exposure to the field affects a woman's decision to pursue orthopedics. We performed a prospective, nonrandomized cohort study between academic years 2005 and 2009 and compared interest in orthopedic surgery among female (n=271) and male (n=71) medical students at 2 urban teaching institutions. Elective lectures and orthopedic literature were distributed via e-mail to the study participants. These materials included articles published in the medical literature, materials produced and distributed by the American Academy of Orthopaedic Surgeons, and Web sites providing educational materials. The primary outcome was the likelihood of application for orthopedic residency. We studied the influence of demographics, exposure, and attitudes on interest in pursuing an orthopedic career. Men had a significantly higher baseline level of interest in orthopedic surgery than women (P=.005). Younger age (P<.001) and personal (P<.001), independent (P<.001), and school (P=.023) exposures to orthopedics were significantly related to interest among women. At final follow-up, total personal exposures (P=.003) and total independent exposures (P<.001) in the form of our literature and lectures were correlated with final interest in women. Female interest was decreased by the long hours, physical demands, and predominantly male nature of the field. Early exposure to orthopedic educational resources may be useful in generating female interest. Perceptions and attitudes regarding orthopedic surgery must to be changed to attract the best and brightest minds, regardless of sex.

Biceps Suspension Procedure for Treatment of Painful Inferior Glenohumeral Subluxation in Hemiparetic Patients

Introduction

This article describes our biceps suspension procedure for painful inferior subluxation of the glenohumeral joint in hemiparetic patients.

Step 1 Position Patient and Expose the Biceps Tendon

Position the patient supine and expose the long head of the biceps tendon.

Step 2 Create Tunnel

Use a curet to connect holes drilled at the superior and inferior aspects of the lesser tuberosity.

Step 3 Prepare Biceps Tendon

Incise the tendon at the musculotendinous junction to preserve as much length of the biceps tendon as possible.

Step 4 Create Suspension

Create a loop with the tendon, and suture the distal end to the proximal end.

Step 5 Postoperative Protocol

Use a sling for three months, followed by active range-of-motion exercises.

Results

In summary, all patients noted pain relief after surgery, ten (of eleven) noted decreased deformity, and nine were "very satisfied" with the outcome.

What to Watch For

IndicationsContraindicationsPitfalls & Challenges.

Shoulder tenotomies to improve passive motion and relieve pain in patients with spastic hemiplegia after upper motor neuron injury

HYPOTHESIS

Shoulder adduction and internal rotation contractures commonly develop in patients with spastic hemiplegia after upper motor neuron (UMN) injury. Contractures are often painful, macerate skin, and impair axillary hygiene. We hypothesize that shoulder tenotomies are an effective means of pain relief and passive motion restoration in patients without active upper extremity motor function.

MATERIALS AND METHODS

A consecutive series of 36 adults (10 men, 26 women) with spastic hemiplegia from UMN injury, shoulder adduction, and internal rotation contractures, and no active movement, who underwent shoulder tenotomies of the pectoralis major, latissimus dorsi, teres major, and subscapularis were evaluated. Patients were an average age of 52.2 years. Pain, passive motion, and satisfaction were considered preoperatively and postoperatively.

RESULTS

Average follow-up was 14.3 months. Preoperatively, all patients had limited passive motion that interfered with passive functions. Nineteen patients had pain. After surgery, passive extension, flexion, abduction, and external rotation improved from 50%, 27%, 27%, and 1% to 85%, 70%, 66%, and 56%, respectively, compared with the normal contralateral side (P < .001). All patients with preoperative pain had improved pain relief at follow-up, with 18 (95%) being pain-free. Thirty-five (97%) were satisfied with the outcome of surgery, and all patients reported improved axillary hygiene and skin care. Age, gender, etiology, and chronicity of UMN injury were not associated with improvement in motion.

DISCUSSION

We observed improvements in passive ROM and high patient satisfaction with surgery at early follow-up. Patients who had pain with passive motion preoperatively had significant improvements in pain after shoulder tenotomy.

CONCLUSION

Shoulder tenotomy to relieve spastic contractures resulting from UMN injury can be an effective means of pain relief and improved passive range of motion in patients without active motor function.

Outcomes of the biceps suspension procedure for painful inferior glenohumeral subluxation in hemiplegic patients

BACKGROUND

Patients with upper motor neuron injury can develop painful inferior glenohumeral subluxation with functional impairment. If the pain is relieved by manual reduction of the subluxation, this pain is considered mechanical in nature and potentially amenable to surgical treatment to maintain this reduction. The purpose of this study was to report our outcomes with use of the biceps suspension procedure to achieve shoulder joint reduction and pain relief in hemiplegic patients.

METHODS

This retrospective case series of eleven consecutive hemiplegic patients with painful glenohumeral subluxation underwent surgical reduction with a biceps suspension procedure. Seven patients had, in addition, extra-articular tenotomies to treat coexisting muscular contractures. Pain, physical examination findings, and radiographs were evaluated before and after surgery. Patient satisfaction with the outcome of the surgery was determined as well.

RESULTS

The mean duration of the patient follow-up was 3.2 years (range, 2.0 to 5.8 years). The average patient age was 46.9 years (range, eighteen to eighty-one years). Ten of the patients were female. All patients had pain with passive shoulder motion preoperatively, but only one patient had such pain postoperatively (p < 0.001). At the time of follow-up after the surgery, the mean score for pain on a visual analog scale was 1.45 (range, 0 to 5), with all patients noting a decrease in pain. Ten patients noted that deformity was also decreased at the time of follow-up. All patients had a sulcus sign on physical examination preoperatively, but only three had such a sign postoperatively (p < 0.001). The seven patients who had undergone shoulder tenotomies had significant improvements in shoulder extension (p = 0.009), forward elevation (p = 0.030), abduction (p = 0.040), and external rotation (p = 0.043) postoperatively. Ten patients were satisfied with the outcome of the surgery. Preoperative radiographs demonstrated inferior subluxation of the humeral head at the glenohumeral joint in all patients. Postoperatively, ten patients had an improved glenohumeral joint position, and nine of these patients had complete reduction of the humeral head.

CONCLUSIONS

Biceps suspension surgery can provide pain relief in hemiplegic patients with painful subluxation of the humeral head after upper motor neuron injury. Tenotomy of contracted muscles around the shoulder can improve passive shoulder motion in patients with spastic hemiplegia. Following surgery, there were high rates of glenohumeral reduction and patient satisfaction.

Efficacy of median nerve recurrent branch neurectomy as an adjunct to ulnar motor nerve neurectomy and wrist arthrodesis at the time of superficialis to profundus transfer in prevention of intrinsic spastic thumb-in-palm deformity

PURPOSE

The superficialis to profundus (STP) tendon transfer is an effective procedure to correct a spastic clenched fist deformity in a nonfunctional upper extremity. An intrinsic thumb-in-palm (TIP) deformity, caused by increased activity in the adductor pollicis and flexor pollicis brevis muscles, commonly becomes apparent after an STP procedure. The goal of this study was to investigate the efficacy of median nerve recurrent branch neurectomy, done at the time of STP and in concert with an ulnar motor nerve neurectomy and wrist arthrodesis, in the prevention of an intrinsic TIP deformity caused by spastic thenar muscles.

METHODS

We retrospectively evaluated a consecutive series of 23 patients with upper motor neuron syndrome who underwent an STP transfer performed by a single surgeon at our institution. Group 1 included 11 consecutive patients who underwent an STP, ulnar nerve motor branch neurectomy, and wrist arthrodesis. Group 2 included 12 consecutive patients who underwent the same procedures with the addition of a neurectomy of the recurrent median nerve. We examined outcomes including development of a postoperative intrinsic TIP deformity, resolution of hygiene issues, and the need for additional surgery to correct the remaining deformities.

RESULTS

Patients were observed for an average of 16.1 months. In group 1, 5 of 11 patients developed an intrinsic TIP deformity, compared with 2 of 12 in group 2. Hygiene-related issues resolved in 8 of 11 patients in group 1 and 10 of 12 patients in group 2. There were no wound infections. In the 7 patients with postoperative intrinsic TIP deformity (5 in group 1 and 2 in group 2), 5 elected to have additional surgery. Of the 7 patients, 2 declined additional surgery because their deformities were mild and their hygiene issues had resolved.

CONCLUSIONS

Median nerve recurrent branch neurectomy appears to be a useful adjunct to STP with ulnar motor branch neurectomy and wrist arthrodesis in the prevention of an intrinsic TIP deformity in the nonfunctional hand.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Orthopaedic issues in the musculoskeletal care of adults with cerebral palsy

AIMS

Orthopaedic care of adults with cerebral palsy (CP) has not been well documented in orthopaedic literature. This paper focuses on some of the common problems which present themselves when adults with CP seek orthopaedic intervention. In particular, we review the most common orthopaedic issues which present to the Penn Neuro-Orthopaedics Program.

METHOD

A formal review of consecutive surgeries performed by the senior author on adults with CP was previously conducted. This paper focuses on the health delivery care for the adult with orthopaedic problems related to cerebral palsy. Ninety-two percent of these patients required lower extremity surgery. Forty percent had procedures performed on the upper extremities.

RESULTS

The majority of problems seen in the Penn Neuro-Orthopaedics Program are associated with the residuals of childhood issues, particularly deformities associated with contractures. Patients are also referred for treatment of acquired musculoskeletal problems such as degenerative arthritis of the hip or knee. A combination of problems contribute most frequently to foot deformities and pain with weight-bearing, shoewear or both, most often due to equinovarus. The surgical correction of this is most often facilitated through a split anterior tibial tendon transfer. Posterior tibial transfers are rarely indicated. Residual equinus deformities contribute to a pes planus deformity. The split anterior tibial tendon transfer is usually combined with gastrocnemius-soleus recession and plantar release. Transfer of the flexor digitorum longus to the os calcis is done to augment the plantar flexor power. Rigid pes planus deformity is treated with a triple arthrodesis. Resolution of deformity allows for a good base for standing, improved ability to tolerate shoewear, and/or braces. Other recurrent or unresolved issues involve hip and knee contractures. Issues of lever arm dysfunction create problems with mechanical inefficiency. Upper extremity intervention is principally to correct contractures. Internal rotation and adductor tightness at the shoulder makes for difficult underarm hygiene and predispose a patient to a spiral fracture of the humerus. A tight flexor, pronation pattern is frequently noted through the elbow and forearm with further flexion contractures through the wrist and fingers. Lengthenings are more frequently performed than tendon transfers in the upper extremity. Arthrodesis of the wrist or on rare occasions of the metacarpal-phalangeal joints supplement the lengthenings when needed.

CONCLUSIONS

The Penn Neuro-Orthopaedics Program has successfully treated adults with both residual and acquired musculoskeletal deformities. These deformities become more critical when combined with degenerative changes, a relative increase in body mass, fatigue, and weakness associated with the aging process.

Effect of age, sex, and timing on correction of spastic equinovarus following cerebrovascular accident

BACKGROUND

Spastic equinovarus (SEV) is the most common leg deformity after cerebrovascular accident (CVA). This study reviewed functional outcomes after surgical correction of SEV in a cohort of hemiplegic, post-CVA patients.

METHODS

Sixty-four consecutive post-CVA SEV patients who underwent surgical correction from January 2003 to January 2006 were included. Data parameters included age, sex, duration since CVA, preoperative orthotic and ambulatory requirements, and Viosca ambulation scores. There were 45 females and 19 males. Average age was 54 (range, 24 to 74) years. Average duration from CVA to surgery was 66 (range, 17 to 523) months. Mean followup was 50.1 (range, 12 to 168) weeks. Final outcomes included status of correction, bracing needs, use of assistive devices, and Viosca score. Univariate and multivariate statistical analyses were performed to determine if age, sex, and time from CVA to surgery affected outcome.

RESULTS

All feet were corrected to plantigrade position. Of the 48 patients who used orthoses preoperatively, 27 (56%) continued use while 11 (44%) were brace-free postoperatively. Of the 23 patients that used an ambulatory assistive device preoperatively, 12 (52%) continued use and 11 (47.8%) were free of assistive devices postoperatively. Median Viosca score improved from two (Independent Household Ambulation) to three (Independent Neighborhood Ambulation) (p < 0.001). There was no statistical association between age, sex, CVA chronicity and outcome parameters.

CONCLUSION

These results indicate that surgical correction of SEV is effective in post-CVA patients. Patients demonstrated improvement in ambulation score regardless of age, sex, or duration from CVA to surgery.

Radiation therapy for preventing recurrence of neurogenic heterotopic ossification

Radiation therapy is commonly used to prevent heterotopic ossification, and the dose-dependent effects of this treatment have been well documented in patients after total hip arthroplasty (THA). However, the efficacy and dose requirement of radiation therapy to prevent heterotopic ossification of nonsurgical origin have not been studied. The purpose of this retrospective case-control study was to determine the effects of prophylactic radiation therapy on severe heterotopic ossification recurrence, postoperative range of motion (ROM), and wound healing in patients with heterotopic ossification secondary to neurologic deficits. Selection was not blinded, and higher risk patients were generally assigned to the treatment group. Standard doses of radiation therapy did not adequately lower recurrence rates; in fact, there was a higher incidence of heterotopic ossification formation necessitating revision in the treatment group (15.0%) compared to the control group (5.1%). Moreover, patients who received radiation therapy were not more successful at maintaining intraoperative ROM over time. There was a similar incidence of delayed wound healing between groups (12.8% in the control group and 12.5% in the treatment group), and no other negative side effects or complications were observed. These results suggest that the 700 cGy dose of radiation therapy typically used for the prophylaxis of heterotopic ossification associated with THA does not effectively prevent the recurrence of neurogenic heterotopic ossification in high-risk patients. Further studies are needed to determine whether higher doses of radiation therapy will provide more effective prophylaxis for heterotopic ossification.

Fixation techniques for split anterior tibialis transfer in spastic equinovarus feet

Equinovarus of the foot is the most common lower extremity deformity following traumatic brain injury. We evaluated outcomes of the split anterior tibialis tendon transfer (SPLATT) for correction of equinovarus in 47 patients with hemiplegic traumatic brain injury and specifically studied differences in outcomes with two tendon fixation techniques. Seventeen patients constituting Group I underwent fixation with one technique and 30 constituting Group II had another technique. Patients in both groups had appropriate procedures based on dynamic electromyography and gait analyses. Both groups were demographically comparable. All 47 feet were corrected to plantigrade position. Thirty-six of 47 patients became brace-free at final followup. There was a notable decrease in the use of ambulatory aids and ambulatory status improved in both groups. There were three fixation-related complications in Group I and none in Group II. Surgical correction of the spastic equinovarus with SPLATT, in the appropriate patient, with or without associated tendon procedures helps to achieve and maintain correction, improves the ambulatory status of the patient, and eliminates the need for bracing in as much as 77% of patients. We recommend the Group II construct owing to the considerably lower complication rate.

Musculoskeletal pain in polio survivors and strength-matched controls

OBJECTIVES

To determine whether a significant difference exists between musculoskeletal symptoms of polio survivors and those of older adults with no history of polio, and to determine if activity level and strength predict pain in either group.

DESIGN

Matched research design.

SETTING

A research laboratory in a rehabilitation setting.

PARTICIPANTS

Fifty-four polio survivors and 54 adults with no history of polio were matched for gender, race, and bilateral knee extensor strength and selected from a cohort of 316 subjects who participated in a study on the relation between activity level and health status.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Location and severity of musculoskeletal pain, activity frequency and intensity level, maximum voluntary isometric strength, and physical performance measures.

RESULTS

Polio survivors reported significantly more symptoms than the matched controls ( P <.05). Symptom status among the polio survivors was strongly associated with performance strain, perceived exertion, and activity intensity. Although the polio survivors had activity frequencies and habitual walking speeds that were similar to those from the matched controls, there was evidence that they performed activities at higher intensity levels.

CONCLUSIONS

Activity level is a factor in the development of musculoskeletal symptoms in polio survivors. Polio survivors who perform at higher intensity levels are more likely to have moderate to severe pain and more mobility difficulties.

The influence of dynamic polyelectromyography in formulating a surgical plan in treatment of spastic elbow flexion deformity

OBJECTIVE

To determine the influence of motor-control analysis with dynamic electromyography on surgical planning in patients with spastic elbow flexion deformity.

DESIGN

Prospective observational design.

SETTING

A Traumatic Brain Injury Model Systems-affiliated specialty referral center for the evaluation and treatment of mobility problems associated with neurologic injury and disease.

PARTICIPANTS

Twenty-one patients with spastic elbow flexion deformity.

INTERVENTIONS

Two surgeons each formulated a detailed surgical plan for each individual muscle-tendon unit. Patients then underwent motor-control analysis in which kinetic and polyelectromyographic data were collected by using a standard protocol. Each surgeon formulated another surgical plan after independently reviewing the laboratory study.

MAIN OUTCOME MEASURES

The frequency of change and degree of agreement in the surgical plans after review of the laboratory data were used as measures of the effect of the laboratory studies.

RESULTS

Fifty-seven percent of the surgical plans were changed after the motor-control study. The frequency of change did not differ by clinical experience. There was a trend toward higher agreement between surgeons after the study than before.

CONCLUSIONS

Detailed electromyographic motor-control analysis alters surgical planning for patients with spastic elbow flexion deformity. Clinical assessment alone does not accurately identify the muscles responsible for the deformity or dysfunction. More clinical experience does not result in greater accuracy. Motor-control analysis produces higher agreement between surgeons in planning surgery.

A comparison of the effects of exercise and lifestyle modification on the resolution of overuse symptoms of the shoulder in polio survivors: a preliminary study

OBJECTIVE

To compare the effectiveness of exercise and lifestyle modification therapy in treating shoulder symptoms in polio survivors with lower-extremity weakness.

DESIGN

A randomized parallel group study.

SETTING

Research laboratory.

PARTICIPANTS

Twenty-three subjects recruited from a cohort of 194 polio survivors who had participated in a previous study had bilateral hip-extensor and knee-extensor weakness and reported experiencing shoulder pain on a regular basis with daily activity.

INTERVENTIONS

Subjects were randomly assigned to 1 of 3 treatment groups. Members of group 1 were placed on a home exercise program that focused on strengthening their hip and knee extensors. Members of group 2 were instructed in lifestyle modification techniques designed to avoid shoulder overuse. Members of group 3 received both interventions.

MAIN OUTCOME MEASURES

Shoulder symptoms were quantified in terms of number and severity. Isometric strength of bilateral hip and knee extensors was measured with a hand-held dynamometer.

RESULTS

Symptoms improved in all 3 groups. However, members of the exercise-only group (group 1) were the only ones to show a significant difference in both number and severity of symptoms when pre- and posttreatment values were compared.

CONCLUSIONS

Both exercise and lifestyle modification therapies that focus on reducing the stress related to lower-extremity weakness are effective in treating shoulder overuse symptoms in polio survivors. A trend toward greater improvement in shoulder symptoms in subjects who participated in the exercise program and who also showed a trend toward increased knee-extensor strength supports muscle strength and/or endurance as a key factor.

Changes in strength over time among polio survivors

OBJECTIVE

To study changes in the strength of different muscle groups in polio survivors over a period of approximately 9 months.

DESIGN

Longitudinal study.

SETTING

Moss Rehabilitation Research Institute.

PARTICIPANTS

One hundred twenty subjects (57 men, 63 women) were studied on three occasions, each 3 to 5 months apart. Subjects were recruited through the Einstein-Moss Post-Polio Management Program. newspaper advertisements, and polio support groups.

MAIN OUTCOME MEASURES

Isometric strength of 30 muscle groups (16 in upper extremities, 14 in lower extremities) was measured, using a hand-held dynamometer.

RESULTS

Data were analyzed in two separate groups: upper-extremity muscles and lower-extremity muscles. Results for the upper-extremity muscles revealed evidence of a significant deterioration in strength. The amount of deterioration differed among muscles and increased with age. There was also evidence of deterioration in strength in the flexor muscles in the ankle, hip, and knee. However, the rate of deterioration in these muscles was not strongly related to age, time since polio, gender, symptom status, or history of residual weakness.

CONCLUSIONS

Strength is deteriorating among polio survivors at a rate higher than that associated with normal aging. This deterioration is not occurring in the extensor, or so-called "weight-bearing" muscles, but is occurring in many of the upper-extremity muscle groups and in the flexor muscles in the lower extremities.

The relation between lower extremity strength and shoulder overuse symptoms: a model based on polio survivors

OBJECTIVE

To determine the relation between lower extremity weakness and shoulder overuse symptoms among polio survivors. We predicted that individuals with moderate weakness in their leg extensor muscles would use their arms to help compensate for this weakness and would be at high risk for developing symptoms of shoulder overuse.

DESIGN

A cohort study of polio survivors recruited from the Einstein-Moss Postpolio Management Program (Philadelphia), the community, and the surrounding region.

SETTING

A research laboratory at Moss Rehabilitation Research Institute, Philadelphia, PA.

PARTICIPANTS

One hundred ninety-four polio survivors. Demographic and medical history data, symptom data, and strength data were obtained for each.

MAIN OUTCOME MEASURES

Presence or absence of shoulder symptoms and ratings of pain by visual analogue scale were recorded. Strength was measured using a hand-held dynamometer and manual muscle testing.

RESULTS

Shoulder symptoms could be grouped into two distinct clusters based on the type of testing used for assessment. Symptoms elicited by palpation were present in 26% of the subjects and were strongly related to knee extensor strength and weight. These symptoms were more common among women than men (42% and 10%, respectively). Symptoms elicited by resistance tests were present in 33% of the subjects and were seen with equal frequency in both sexes. These symptoms were also related to lower extremity strength, but the specific relationship was not as clear as for the palpation-related symptoms.

CONCLUSIONS

Lower extremity weakness predisposes individuals to shoulder overuse symptoms. Sex and body weight are contributing factors. These results may be generalized to other populations with lower extremity weakness, including the elderly.

Improving calf muscle strength in patients with spastic equinovarus deformity by transfer of the long toe flexors to the Os calcis

The split tibialis anterior tendon transfer (SPLATT), Achilles tendon lengthening, and toe flexor release are proven and effective procedures for correcting a spastic equinovarus deformity of the foot. Paresis is a prominent feature of upper motoneuron syndrome. Lengthening the Achilles tendon, although necessary to correct the equinus, further weakens the gastrocnemius-soleus muscle group. The calf paresis commonly results in the need for an ankle-foot orthosis (AFO) during ambulation. Previous studies have shown that despite the correction of the equinovarus deformity, only one third of patients were able to ambulate without an AFO. The need for continued use of an AFO was because of insufficient calf strength to stabilize the tibia during late stance when the body mass is anterior to the ankle joint. This study prospectively evaluated the results of transfer of the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) to the os calcis in 30 patients. The transfer was done in an effort to augment the strength of the gastrocnemius-soleus muscle complex. Twenty-five patients in group I (the control group) underwent SPLATT, Achilles tendon lengthening, and toe flexor release. Thirty patients in group II (the study group) underwent the identical procedures plus the additional FHL and FDL transfer to the os calcis. Postoperatively, the varus and toe flexion deformities were corrected in all feet. In group II, two feet had a mild residual equinus that did not interfere with ambulation. Of the 11 patients who were not independent community ambulators in group I, 7 (64%) improved ambulatory status by at least one level after surgery. Of the 15 patients who were not independent community ambulators in group II, 14 (93%) improved ambulatory status by at least one level after surgery. In group I, 10 of 25 (40%) of the patients were brace free at follow-up. In group II, 21 of 30 (70%) were brace free at follow-up (c2, P =.025). These results indicate that the addition of an FHL and FDL transfer to the os calcis at the time of SPLATT, Achilles tendon lengthening, and toe flexor release improves calf strength and allows greater increase in function and less reliance on orthotics.

Volkmann's ischemic contracture of the upper extremity

Upper extremity deformity of ischemic contracture usually includes elbow flexion, forearm pronation, wrist flexion, thumb flexion and adduction, digital metacarpophalangeal joint extension, and interphalangeal joint flexion. Treatment of mild contractures consists of either nonoperative management with a comprehensive rehabilitation program (to increase range of motion and strenght) or operative management consisting of infarct excision or tendon lengthening. Treatment of moderate-to-severe contractures consists of release of secondary nerve compression, treatment of contractures (with tendon lengthening or recession), tendon or free-tissue transfers to restore lost function, and/or salvage procedures for the severely contracted or neglected extremity.

Correction of severe spastic flexion contractures in the nonfunctional hand

The superficialis to profundus transfer has been a time-honored treatment of spasticity in nonfunctional hands, but it does not address the many associated problems. Fourteen patients were treated with 15 procedures (1 bilateral) designed to relieve severe flexion contractures of the hand and wrist over a 3-year period with a single-stage comprehensive surgical correction consisting of superficialis to profundus transfer, wrist flexor release, flexor pollicis longus lengthening, wrist arthrodesis, carpal tunnel release, and ulnar motor branch neurectomy or intrinsic release. For all, nonoperative treatment had failed or there were chronic skin problems. The follow-up period averaged 1 year. In 13 of 15 patients, there was wrist fusion after the index procedure, with 1 patient requiring replating and another uniting after prolonged casting. Two patients had a residual claw hand with only partial correction of a thumb-in-palm deformity. All preoperative hygiene problems and infections resolved. The comprehensive protocol allowed correction of severe contractures of the hand and wrist by a single operation with improved care and appearance of the hand.

Skin surface pressures under short leg casts

Electronic sensors were used to measure skin surface pressures beneath plaster and fiberglass short leg casts. Pressures were recorded after casting, univalving, bivalving, and spreading of casts. Fiberglass resulted in significantly higher pressures than plaster. Beneficial effects of bivalving and cast spreading are confirmed by significant pressure drops. Application of casts by different orthopaedic surgeons and technologists showed pressure differences due to operator technique. However, fiberglass pressures again proved to be significantly greater than those caused by plaster. Excessive pressure beneath casts can cause skin ulceration, and results confirm the need for extreme care, especially when using fiberglass. It is suggested that plaster is safer than fiberglass when significant extremity swelling is likely or when a patient's skin is more vulnerable to breakdown.

Using dynamic electromyography to guide surgical treatment of the spastic upper extremity in the brain-injured patient

Upper extremity deformity after brain injury is frequently complex and dominated by spasticity or contracture. Clinical examination of the limb is often difficult and inaccurate. Dynamic electromyography provides valuable information previously unobtainable. Analysis of this data can facilitate appropriate reconstruction of the deformed limb.

Deep-venous thrombosis of the upper extremity after traumatic brain injury

Deep-venous thrombosis (DVT) of the lower extremity occurs frequently in a variety of patients, including those with traumatic brain injury (TBI), during their rehabilitation. Thrombosis of the major veins of the upper extremity is believed to be relatively rare, although it has increased in recent years due to the routine use of indwelling percutaneous central venous catheters. Upper extremity pain and swelling in a TBI patient is commonly attributed to heterotopic ossification, reflex sympathetic dystrophy, or occult fracture. Clinicians may not consider DVT in the differential diagnosis. No longer regarded as a benign disorder, we report the successful outcome in a 27-year-old with TBI who developed an upper extremity DVT after subclavian catheterization. The diagnostic findings, as well as treatment recommendations are reviewed.

Valgus deformities of the feet and characteristics of gait in patients who have rheumatoid arthritis

To investigate the cause of valgus deformity of the hindfoot in patients who have rheumatoid arthritis and to characterize the effects of the deformity on gait, two groups of patients were evaluated clinically, radiographically, and with gait analysis in the laboratory. Group 1 consisted of seven patients who had seropositive rheumatoid arthritis and normal alignment of the feet and Group 2, of ten patients who had rheumatoid arthritis and valgus deformity of the hindfoot. In Group 2, the disease was of longer duration and the feet were more painful than in Group 1. There was no evidence of muscular imbalance, equinus contracture, valgus deformity of the tibiotalar joint, or isolated deficiency of the tibialis posterior (such as weakness, tenosynovitis, or rupture of the tendon) that could have contributed to the development of the valgus deformity. In the patients who had valgus deformity, quantitated electromyography demonstrated that the intensity and duration of activity of the tibialis posterior was significantly increased, apparently in an effort to support the collapsing longitudinal arch of the foot. Gait studies revealed decreases in velocity, stride length, and single-limb-support time, as well as delayed heel-rise in both groups, but the decreases were more marked in the patients who had valgus deformity. The results of this study suggest that valgus deformity of the hindfoot in rheumatoid patients results from exaggerated pronation forces on the weakened and inflamed subtalar joint. These forces are caused by alterations in gait secondary to symmetrical muscular weakness and the effort of the patient to minimize pain in the feet. Radiographs also suggested an association between the valgus deformity of the feet and valgus deformity of the knees in patients who have rheumatoid arthritis.