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.

Neuro-orthopedic management of the dysfunctional extremity in upper motor neuron syndromes.

Orthopedic surgery can help restore extremity function to many patients with upper motor neuron syndromes (UMN). Impairments are divided into those that cause problems with the active function of the extremity versus those that impede passive function. Limb deformities commonly result from both dynamic (spastic) and static (contractural) components. Clinical examination supplemented with dynamic electromyographic studies provides the optimal information for planning the most effective surgical procedures. In the upper extremity, selective lengthening of the shoulder adductors and extensors combined with elbow flexor lengthening can improve forward reach. Lengthening of the forearm pronators and finger flexors will improve hand use. In the lower extremity, standing balance is improved with widening the base of support by correcting hip adduction contractures and equinovarus foot deformities. Improvement of knee flexion during swing phase by a rectus femoris to gracilis transfer will enhance the fluidity and efficiency of walking. Correction of hip and knee flexion contractures will allow a upright posture and dramatically decrease the energy requirement of walking.

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.