A three-year follow-up study of the development of joint contractures in 131 patients with systemic sclerosis

OBJECTIVES

To analyse the correlation between the number of joint-contractures and other major clinical findings in a follow-up study of 131 patients with systemic sclerosis (SSc).

METHODS

The range of motion of joints (ROM), HAQ-DI, and the major clinical characteristics were assessed.

RESULTS

A high frequency of contractures (ROM<75% of the normal) were present at baseline in small joints of the hand (82%), wrists (75%), and shoulders (50%). ROM of the dominant side hand was significantly more decreased compared to the non-dominant side. The number of the upper extremity contractures correlated positively with ESR (p<0.01), CRP (p<0.01), HAQ-DI (p<0.01), and negatively with forced vital capacity (FVC) (p<0.05). The number of contractures was not significantly different in cases with early (≤ 4 years) and late disease duration in both the limited and diffuse subgroups. During the three-year follow-up period, an increase in the number of joint contractures (ROM<75%) was associated with an increase of ESR, modified Rodnan's skin score, and the European Scleroderma Study Group Activity Index by multiple linear regression analysis. Univariate analysis over a six-year period demonstrated poor outcome in patients with more than ten contractures, or more than four contractures of unilateral hand-joints.

CONCLUSIONS

Contractures predominantly develop during the early years following disease onset in both SSc subgroups. Inflammation and skin-involvement are significant contributing factors for the development of contractures. The dominant hand may be more pronouncedly impaired compared to the non-dominant side. A high number of joint-contractures might be an unfavourable prognostic factor in SSc.

Percutaneous Adductor Release in Nonambulant Children with Cerebral Palsy

INTRODUCTION

Adductor spasticity at hips is the main barrier in functional activities and rehabilitation of spastic cerebral palsy patients. The aim of this study is to evaluate the results of percutaneous adductor release under general anaesthesia.

METHODS

From July 2005 to July 2010, 64 hips in 32 patients (19 males and 13 females) were recruited from outpatient department having adductor contracture at hips in cerebral palsy children. All children were operated under general anaesthesia. All children were followed for twenty-four months. The clinical results were evaluated radiologically, including measurement of CE- angle, AC-index and femoral head coverage and in terms of activity level of children.

RESULTS

Of the thirty-two children, twenty-eight showed marked and immediate improvement. None of our children was functionally worse at follow-up. The CE-angle and femoral head coverage did not change significantly. The AC-index improved significantly (P = 0.01).The results were excellent in 12.5% children, good in 50%, fair in 25% and poor in 12.5%.

CONCLUSIONS

Bilateral mini-invasive adductor release can be an effective treatment for children suffering from adductor contracture refractory to nonoperative management and early adductor release can prevent subluxation and possibly the need for future bony procedure on the proximal femur and pelvis.

Pathological trunk motion during walking in children with amyoplasia: is it caused by muscular weakness or joint contractures?

The aim was to investigate the causes for pathological trunk movements during gait in children with Amyoplasia. Eighteen children with Amyoplasia were compared with 18 typically developed children. Three-dimensional motions of pelvis, thorax and spine during gait were analyzed. Excessive trunk movements were defined as being above 4 standard deviations of those of typically developed children. Clinical examination of active strength and passive range of motion of the hip, knee and ankle joints were correlated to the parameter that showed the greatest prevalence of pathological trunk motion. The greatest prevalence of 56% was seen for thorax obliquity range during walking. The spine angles showed the lowest deviations from typically developed children. Significant correlations (p<0.001) between thorax obliquity range and clinical parameters were found for passive hip extension, hip flexion, hip abduction and active hip extension, hip flexion and ankle dorsiflexion strength. The highest correlation coefficients were found for passive hip flexion and active hip flexion strength of rho=-0.73 and rho=-0.69 respectively. Excessive thorax obliquity during gait in children with Amyoplasia could be mainly caused by reduced strength and mobility of the hip. Therefore both mobility and strength of the hip are equally important and should be increased in the therapy to improve gait in children with Amyoplasia.

Clinical and radiographic evaluation of sagittal imbalance: a new radiographic assessment

In this article, we describe a case series study involving a new radiologic evaluation of sagittal imbalance. We review the current radiologic assessment of sagittal imbalance and introduce a new radiologic evaluation that helps in ruling out hip flexion contracture as the primary cause of sagittal imbalance and the type and level of spinal osteotomy required to regain sagittal balance. Sagittal imbalance is important in spinal deformity assessment. Studies have confirmed that overall clinical outcomes and patient satisfaction with surgery were best in cases that resulted in an increase in lumbar lordosis. For this study, radiologic assessment of sagittal imbalance was conducted on a long, 14 × 51-inch upright lateral plain radiograph that included the proximal femur and the entire spine. The radiograph was taken with the arms at 45° forward flexion and the hips and knees fully extended. The femoral axis line was drawn and extended cephalad. The C7 offset, the perpendicular distance between the femoral axis line and the center of C7, represented the degree of sagittal imbalance. The angle between the femoral axis line and a line extending from the center of C7 to the vertebra at the level of the proposed osteotomy--the Seattle angle--predicted how much correction was required to bring the C7 plumb in line with the femoral axis and to decrease the C7 offset, thus regaining sagittal balance. The proposed method was used to evaluate 10 consecutive patients who required spinal osteotomies to regain sagittal balance. Preoperative and postoperative plain radiographs were assessed twice, at a 6-week interval, by an independent spine surgeon and a musculoskeletal radiologist. Cohen κ correlation coefficients were used to calculate intraobserver and interobserver reliability. The 2 reviewers' intraobserver reliability was excellent (κs = 0.98, 0.93). Interobserver reliability was lower but good (κ = 0.76). Inclusion of the proximal femur on the long upright lateral plain radiograph of the entire spine and identification of the relation between the femoral axis line and the center of C7 are important in evaluating sagittal imbalance. Excellent intraobserver reliability, coupled with good interobserver reliability, suggest that this new radiologic assessment method can be helpful in preoperative assessment of sagittal imbalance.

[Release of gluteal muscle contracture by radiofrequency under arthroscopy]

OBJECTIVE

To evaluate the clinical therapeutic effect of the release of gluteal muscle contracture by radiofrequency under arthroscopy.

METHODS

From January 2004 to April 2005, 86 patients with gluteal muscle contracture were treated by radiofrequency release under arthroscopy.The patients were followed-up for 6-18 months(mean=12.6 months).

RESULTS

Getting carriage, squatting down while keeping their knees contacting, crossing leg test, and impact on movement were served as evaluation criteria. Of the 86 patients, 79 had excellent results, 5 good, and the rest 2 were acceptable. There was no recurrence at the last follow-up, and all the patients were satisfied.

CONCLUSION

For gluteal muscle contracture, radiofrequency release under arthroscopy has minimally invasion, good results and quick recovery.

A method to evaluate contractures effects during the gait of children with Duchenne dystrophy

Joint contractures are the second major impairment affecting the locomotor system of children with Duchenne muscular dystrophy (DMD). While the negative influence of joint contractures has been documented, the passive moments produced by joint contractures could benefit the gait of patients with muscle weakness. We describe a biomechanical model that quantifies the mechanical contribution of ankle and hip flexion contractures to the gait of DMD children. Kinematic and kinetic parameters were measured under the same experimental conditions during the gait and passive resistance assessment of two subjects: one healthy child as a control, and one child with DMD. The child with DMD had a plantar flexion contracture and a greater ankle stiffness coefficient than the control child. During gait, the contribution of the ankle passive moment to the net moment was more important for the child with DMD than for the control child. At the hip, passive joint moments and passive moment contribution were more important for the control child but this was not related to the presence of hip flexion contracture. These preliminary results suggest the model might be used to evaluate contractures effect on a larger cohort of subjects.

Windswept hip deformity in children with cerebral palsy

Windswept hip deformity describes an abduction and external rotation position of one hip with the opposite hip in adduction and internal rotation. Windswept hip deformity may occur in association with hip dislocation and scoliosis. We analysed the prevalence of this deformity in a total population of children with cerebral palsy, and the impact of hip prevention and early treatment of contractures on the prevalence and severity of windswept hip deformity. The frequency of windswept hip deformity was 12% in the control group and 7% in the study group, comprising children in the hip prevention programme. The children with this deformity in the study group had a lower frequency of scoliosis and none had hip dislocation. It thus seems that the hip prevention programme results in a decrease in the number of children with windswept hip deformity, and a decrease in the severity of the deformity.

"Syndrome of contractures" (according to Mau) with the abduction contracture of the right hip as causative factor for development of the so-called idiopathic scoliosis

The article provides basic explanation of "syndrome of contractures" (Mau) at newborns and babies and it's conjunction with biomechanical etiology of the so-called idiopathic scoliosis (Karski 1995-2006). The authors analyzed children with "syndrome of contractures" and noted its relevance to some clinical symptoms at children with scoliosis. Newborns and babies with clinical signs of "syndrome of contractures" require further spine examination already at age of 3-4 in order to detect "danger of oncoming scoliosis" and to introduce neo-prophylaxis. The research based on "syndrome of contractures" can explain predominance of female gender of patients with scoliosis, sides of curves, side of rib hump, progression and sensibility to new rehabilitation exercises.

Hip flexion contracture and lumbar spine lordosis in myelomeningocele

The objective of this study was to assess the correlation between hip flexion contracture (HFC) and the sagittal alignment of the lumbar spine in ambulatory children with myelomeningocele. Ambulatory patients with myelomeningocele are generally free of scoliosis or kyphosis. Among them, some develop increased lumbar lordosis. It is postulated that HFC and increased lumbar lordosis may be correlated. Thirty-eight patients, with a mean age of 12.7 years, were evaluated. Standing lateral spine films were obtained and the lumbar lordosis was measured using the Cobb method. HFC was measured using the Thomas test. A statistically significant correlation was found between the lumbar curve and HFC. High values of lumbar Cobb angle (hyperlordosis) were correlated with high values of HFC. These results show a correlation between HFC and increased lumbar lordosis in ambulatory myelomeningocele patients.

Common rotational variations in children

Most rotational variations in young children, such as in-toeing, out-toeing, and torticollis, are benign and resolve spontaneously. Understanding the normal variations in otherwise healthy children is vital to identifying true structural abnormalities that require intervention. A deliberate assessment of the rotational profile is necessary when evaluating children who in-toe or out-toe. In-toeing is usually attributable to metatarsus adductus in the infant, internal tibial torsion in the toddler, and femoral anteversion in children younger than 10 years. Out-toeing patterns largely result from external rotation hip contracture, external tibial torsion, and external femoral torsion. Although congenital muscular torticollis is the most common explanation for the atypical head posture in children, more serious disorders, including osseous malformations, inflammation, and neurogenic disorders, should be excluded.

Proximal femoral resection for subluxation or dislocation of the hip in spastic quadriplegia

Management of a painful or contracted hip dislocation in individuals with severe spastic quadriplegia is difficult. Clinical and radiographic results of 12 proximal femoral resection-interposition operations performed in seven non-ambulatory persons (five males, two females; mean age 14 years, 8 months; age range 6 years 11 months to 19 years 8 months) with severe spasticity were reviewed to determine if pain relief and restoration of motion were maintained. At a mean follow-up of 7 years 7 months (median 9 years 6 months) all participants maintained a good sitting position and a functional range of motion with improved hygiene. Hip pain was improved in all participants compared with their preoperative status. Proximal femur migration occurred causing slight pain in one person. Heterotopic ossification was observed but was not clinically significant. Complications included traction pin loosening and infection and a late supracondylar femur fracture 3 months after the operation. Proximal femoral resection effectively decreased pain and restored hip motion in those with severe spastic quadriplegia leading to improved sitting and perineal care.

[Rotation-abduction contracture of the hip joint]

The paper presents the rotation-abduction contracture of the hip, a problem of growing magnitude in recent years. The anatomy of the hip joint, the perils related to muscle physiology, the symptoms of the disease, the etiology and means of surgical treatment according to Fernandez de Valderrama and Esteve de Miguel are discussed. The results of surgical treatment of 12 patients at the Orthopedic Department of Wroclaw. The presented procedure has been used in our center since 1993, and the results encourage further use of this technique.

Proximal rectus femoris lengthening

There are two main problems with muscle tendon lengthening: thinness created by the technical procedure weakens the tendon, and in short tendons, lengthening may not provide enough length for the amount of joint motion required. In proximal rectus femoris lengthening, the distal ends of the reflected and straight heads are sutured together. Using this technique, the tendon will not be thinned, and a later second lengthening is possible.

The effect of soft tissue release of the hips on walking in myelomeningocele

Walking and standing capacity in myelomeningocele is highly dependent on the level of the neurological lesion. Deformities, mainly flexion deformities, of the hip can severely interfere with mobility. In a retrospective study, undertaken in our hospital, we evaluated the role of soft tissue release of the hip in patients with hip flexion contractures. A special surgical technique was performed in 55 hips. The results show a good effect on verticalization, even if the hip joints cannot be extended actively. A subluxated or dislocated hip did not influence the final outcome. During the mean follow-up of approximately 4 years, only a slight recurrence of the former deformity was observed. Most of the patients obtained great advantage from the operation.

Predicting the outcome of adductor tenotomy

This study reviewed 57 hips in 30 children (18 girls and 12 boys) with cerebral palsy who had undergone an adductor tenotomy alone or in combination with an anterior obturator neurectomy (23 hips). Results were evaluated by the Reimers migration percentage (MP). The hips were split into three groups: group A (12 hips) a preoperative MP of less than 20%, group B (25 hips) between 20 and 40%, and group C (20 hips) more than 40%. The mean age at the time of surgery was 6 years and 1 month (range: 2.5-13 years). The mean period of review was 6 years and 3 months (2-20 years). The results were considered as "good" when radiographs at the longest follow-up showed a decrease of > 10% of the MP, as "bad" when they showed an increase of > 10%, and as "stable" when the MPs varied less than 10%. At the latest review of group A, 11 were stable (92%) and 1 was bad. In group B, 12 were stable (48%), 7 were good (28%), and 6 were bad (24%). In group C, 7 were stable (35%), and 13 were bad (65%). The preoperative migration percentage provided to be the only predictor of outcome. Age at the time of surgery had no constant significant effect on the outcome, neither had the addition of an anterior neurectomy.

Soft tissue balance of the hip

Release of static and dynamic contractures around the hip provides significant immediate benefits for the patient and accelerates postoperative rehabilitation. Knee pain is decreased, groin pain is eliminated, range of motion of the hip is increased, and functional leg-length difference is reduced. This article emphasizes the importance of techniques used to ensure soft tissue balance.

Dynamic implications of hip flexion contractures

Hip flexion contractures are a common complication in disabled patients. However, no previous study has examined reduced hip motion during gait. This retrospective analysis evaluates the relationship between the degree of hip flexion contracture found on static testing and the degree found during gait and also assesses the strength of the association between hip flexion contractures and compensatory mechanisms such as anterior pelvic tilting, increased knee flexion, and decreased contralateral step length. Clinical and quantitative gait laboratory data were obtained from 41 consecutive patients with mostly neurologically based impairments who presented with bilateral hip flexion contractures on Thomas testing (82 limbs). Correlation studies demonstrated a relatively weak association between the degree of peak hip extension during gait and hip flexion contracture by Thomas testing (r = 0.41, P < 0.0001). Limited hip extension was most closely associated with anterior pelvic tilting (r = 0.60, P < 0.0001), whereas Thomas test measurements yielded a correlation with anterior pelvic tilt of only r = 0.36 (P < 0.001) and were insignificant predictor variables of anterior pelvic tilting in regression analysis. Thus, peak hip extension and anterior pelvic tilting assessed during gait were poorly associated with the static Thomas test measurements, and anterior pelvic tilt was most strongly correlated with reduced hip extension during gait compared with the other compensatory mechanisms.

Factors affecting appearance patterns of hip-flexion contractures and their effects on postural and gait abnormalities

Hip flexion contractures accompanying various orthopedic and neurologic conditions not only limits the physical activities of the patients but also distorts their postures and gait patterns. The purposes of this study were to characterize the appearance patterns of flexion contracture at the hip joints and to elucidate how this disability affects their postural and gait abnormalities. Seventy-eight patients (mean age of 68.1 +/- 10.5 years) with hemiplegia, femoral neck fractures, osteoarthritis of the hip and other conditions causing hip flexion contractures were studied. The presence and degree of hip flexion contracture were estimated in the supine position using the Thomas maneuver with a goniometer. Relationship between appearance patterns and 12-survey variables was also analyzed statistically. As a result, it was revealed that whether lack of mobility caused by hip flexion contracture was compensated for by pelvic tilt an an increase of lumbar lordosis or not was affected by four factors. It was also revealed that whether it appeared unilaterally or bilaterally was affected by five factors. In addition, some postural and gait abnormalities caused by hip flexion contracture were observed in many patients. These results suggest that clinical pictures of the patient's posture and gait abnormality depend on his ability to regulate the position of the trunk and knees as well as the mobility of his spine.

Camptocormia: a biomechanical analysis. A case report

Although camptocormia, a conversion disorder associated with the disability of severely forward-bent posture, has been reported in the literature, to date there has been no report of a detailed kinematic or biomechanical analysis of this disability. Presented is a 47-yr-old male engineer with severely forward-bent posture during walking. One year ago, after playing tennis, he developed low back pain followed by a sensation that to walk comfortably he had to assume a forward-bent posture. Two months later, although the low back pain had resolved, he maintained the same unusual walking pattern. Although he could walk a few steps in the upright position, he would spontaneously revert to the forward-bent posture. Physical examination was normal except for bilateral 10 degree hip flexion contractures. Gait laboratory analysis, including kinematics, kinetics, and dynamic electromyography, revealed exaggerated anterior pelvic tilt during terminal stance when he walked in an upright posture. In the forward-bent posture, however, this anterior pelvic tilt was significantly less. It is possible that his unusual forward-bent posture was a compensatory mechanism to reduce excessive pelvic tilt. Although this rare disability has been previously attributed to a conversion disorder, there may be, in some instances, a biomechanical component.

Paraplegia and congenital contractures as a consequence of intrauterine trauma

We present a newborn infant with paraplegia and contractures of the lower limbs, consistent with neurologic injury rather than malformation. The mother was involved in a severe motor vehicle accident during the sixth month of pregnancy. We propose that this infant's injuries are a result of that accident.

A new case of Ullrich's disease

A new case of congenital, hypotonic-sclerotic muscular dystrophy is presented. The patient showed congenital hyperlaxity and looseness of distal joints, muscle weakness, and spur-like protrusion of the calcaneus. Afterwards rapid progressive contractures of both knees and hip joints developed. Muscle biopsies revealed unequivocal dystrophic abnormalities and small atrophic fibers with numerous foldings of basal lamina suggestive of a neurogenic lesion. The disease presents clinical variability but the diagnosis is possible when a newborn shows: no dominant family history, slender body, marked distal joint laxity and hyperflexibility, proximal joint contractures and normal or slightly increased serum enzymes.

Extension-abduction contracture of the spastic hip

Patients with cerebral palsy and fixed hip extension are often unable to sit and therefore lose social and educational opportunities. At Texas Scottish Rite Hospital (Dallas, TX, U.S.A.), 29 patients had hip extension-abduction contractures. Eleven patients with mild involvement were managed with physical therapy. Six patients had moderate involvement and required wheelchair modification to maintain sitting. Twelve patients demonstrated severe contractures that required major soft tissue releases and often femoral shortening osteotomies to regain flexion. Patients with athetosis or rigidity were identified as those most likely to develop extension-abduction contractures either spontaneously or following adductor releases.

Joint motion limitation in newborns

Fifty neonates were evaluated and followed for 2 years with attention to the passive range of joint motion. Passive range of motion was symmetrical throughout this period. Only the hips were noted to have persistent contractures in flexion and external rotation during these 2 years. Such deformities of the hip make judgements about anteversion in infancy difficult. They also help explain the peculiarity of the lordotic, externally rotated gait seen initially in many toddlers.

Contracture of the hip secondary to fibrosis of the gluteus maximus muscle

Twenty-eight children were treated who had limited flexion of the hips and various degrees of contracture of the abductor and external rotator muscles because of fibrosis of the gluteus maximus muscle. Although the lesions could be classified as those associated with poliomyelitis, infection of the gluteus maximus muscle, and fibrosis of unknown etiology, all forty-five hips had a typical restriction of motion such that an affected hip could not be flexed in the usual sagittal plane, but had to be flexed in abduction. Poliomyelitis may have been adjunctive to the causative factor of the lesion in some cases but the probable primary etiology was multiple intramuscular injections. Excellent correction of the hip contracture was achieved in all patients by division of the fibrotic bands.

Myelodysplasia. The influence of the quadriceps and hip abductor muscles on ambulatory function and stability of the hip

In an analysis of motor function, ambulatory function, and hip stability in sixty-five patients with myelodysplasia, four motor-function groups based on the strength of the quadriceps and hip abductor muscles were identified. Retrospectively, it was evident that based on these groups, it would have been possible to predict which hips would remain stable, what level of ambulatory function the patients could achieve, and whether treatment to reduce and stabilize the hips was indicated. Fifty-seven of fifty-eight hips in the twenty-nine patients with functioning quadriceps muscles but non-functioning hip-abductor muscles were either subluxated or dislocated. Thirty-nine of the remaining forty-six patients with functioning quadriceps muscles could walk. In this series, three operative procedures were used to treat hip subluxation: varus osteotomy, varus osteotomy combined with iliopsoas transfer, and iliopsoas transfer alone. One shelf procedure was also done. Varus osteotomy was the best procedure for hip subluxation while posterior iliopsoas transfer, either alone or in combination with a varus osteotomy, was of questionable value. Treatment of hip instability (subluxation or dislocation) in patients without quadriceps function was not necessary.

The prone hip extension test: a method of measuring hip flexion deformity

The "prone hip extension test" is described as a simple, convenient, and reliable method of measuring hip flexion contracture. The test may be performed on a padded examining table or bed, it is applicable to the spastic patient, and as the patient is examined prone, it provides a method of flattening the lumbar spine under visual control to avoid obtaining either a falsely high or low value. It, therefore, circumvents the problems commonly associated with the traditional "Thomas Test".

Electromyography before and after surgery for hip deformity in children with cerebral palsy. A comparison of clinical and electromyographic findings

Twenty-three ambulatory children with spastic diplegic cerebral palsy were evaluated clinically and by electromyography before and after hip-muscle surgery. The stretch tests originally designed to distinguish specific muscle tightness and spasticity were found to be non-specific when tested by electromyography. Ambulatory electromyograms using needle electrodes and telemetry generally showed decreased activity in the released muscles and, on occasion, changes in activity in muscles not operated on. These unanticipated changes after release may explain some of the unpredictability of results of such procedures in cerebral palsy.

Evaluation of the hip

This paper deals with clinical evaluation of the hip. Methods of testing for mobility in the hip joint are discussed. Analysis of gait and functional activities as related to muscle imbalance is presented. Gross techniques of manual muscle testing and basic principles of specific manual muscle testing are presented.