Analysis of compartment syndromes in lower extremity pediatric and adolescent trauma - are there predictors of a late onset?

INTRODUCTION: Purpose of the study was to answer the question, if there are common fracture or injury characteristics, which help to identify patient at risk for a secondary compartment syndrome. MATERIALS AND METHODS: Between 2003 and 2022 all children and adolescents who were treated for a traumatic compartment syndrome in a lower extremity were retrospectively evaluated. Patient's demographics were recorded, the underlying trauma mechanism identified. Fractures were classified, treatment and complications were analyzed. We differentiated two groups of patients (early onset vs. late onset) and compared trauma mechanism, fracture location, classification and treatment between those two entities. RESULTS: Our collective consisted of 56 children and adolescents with 67 compartment syndromes, with an average age of 14.1 years (5-17). 41 (73.2 %) of the patients were male and 15 (26.8 %) female. Most people in our sample had previously been involved in traffic accidents (64.3 %), with the most common mechanism of injury being "motorbike accident" (34.3 %) and "pedestrian/cyclist accident against car" (26.9 %). There was an accumulation of fractures of the lower leg, in particular tibial shaft fractures (AO 42 and 43A; 49.3 %). In our survey, dislocated fractures and fractures of the foot always led to an early onset of compartment syndrome. The tibial shaft fracture and the surgical treatment with intramedullary nailing showed a significant frequency in the late onset group. CONCLUSIONS: Special attention should be paid to pediatric and adolescent patients with tibial shaft fracture and surgical treatment with intramedullary nailing in order to detect and treat a possible late onset of a compartment syndrome at an early stage.

Effects on gait kinematics, pedobarography, functional and subjective results after isolated chopart injury.

BACKGROUND: This study analysed changes in gait and pedobarography and subjective and functional outcomes after isolated Chopart joint injury. METHODS: The results of 14 patients were reviewed. Kinematic 3D gait analysis, comparative bilateral electromyography (EMG) and pedobarography were performed. RESULTS: On the injured side, the 3D gait analysis showed a significantly increased internal rotation and decreased external rotation of the hip and significantly decreased adduction and decreased range of motion (ROM) for the ankle. On the healthy side, the pedobarography revealed a significantly increased mean force in the forefoot, an increased peak maximum force and an increased maximum pressure in the metatarsal. When standing, significantly more weight was placed on the healthy side. The EMG measurements showed no significant differences between the healthy and injured legs. CONCLUSIONS: After isolated Chopart injuries, significant changes in gait and pedobarography can be seen over the long term.

A salvage procedure: Radial head excision in children and adolescents-short-to-midterm outcomes and overview of the literature.

Purpose: Purpose of the study was to report the outcomes after radial head excision in children and adolescents in addition with a review of the current literature. Methods: We report a series of five children and adolescents, who had undergone a post-traumatic radial head excision. Clinical outcomes were evaluated in terms of elbow/wrist range of motion, stability, deformity and discomforts or restrictions at two follow-up points. Radiographic changes were evaluated. Results: Patient's age at time of the radial head excision averaged 14.6 (13-16) years. Mean time from the injury to the radial head excision was 3.6 (0-9) years. Follow-up I averaged 4.4 (1-8) years and follow-up II 8.5 (7-10) years. At follow-up I, patients showed an average elbow range of motion of 0-10-120° Ext/Flex and 90-0-80° Pro/Sup. Two patients reported discomfort or pain at the elbow. Four (80%) patients had a symptomatic wrist with pain or crepitation at the distal radio ulnar joint. In three (60%) of them, an ulna plus at the wrist was present. Two patients required ulna shortening and autograft stabilization of the interosseous membrane. At final follow-up, all patients reported full functioning with daily activities. Restrictions were present with sport activities. Conclusion: Functional results at the elbow joint might be improved and pain syndromes lessen due to the radial head excision. Problems at the wrist are likely secondary to the procedure. A critical analysis of other options should be performed ahead of the procedure and a careless application should be avoided by all means. Level of evidence: IV.

The impact of knee arthrodesis on gait kinematics, muscle activity and patient-reported outcome.

BACKGROUND: The aim of this retrospective study was to analyze gait kinematicsandoutcome parameters after knee arthrodesis. METHODS: Fifteenpatients with a mean follow-up of 5.9 (range0.8-36) years after unilateral knee arthrodesis were included. A 3D gait analysis was performed and compared to a healthy control group of14patients. Comparative electromyography was performed bilaterally at the rectus femoris, vastuslateralis/medialisand tibialis anterior muscles. The assessment further included standardized outcome scores- Lower Extremity Functional Scale (LEFS) andShort Form Health Survey (SF-36). RESULTS: The 3D analysis showed a significantly shortened stance phase (p = 0.000), an extended swing phase (p = 0.000), and an increased time per step (p = 0.009) for the operated side compared with thenonoperatedside. There were statistically significant differences in the extent of movement of the hips, knees and ankles among the operated andnonoperatedsides and the control group. For the mean EMG measurement, no significant difference was found between the healthy control group and the patients with arthrodesis.The average LEFSscorewas 27.5 ± 10.6out of a maximum of 80 points,and the mean physical total scale and mean emotional total scale scores for the SF-36 were 27.9 ± 8.5and 52.9 ± 9.9, respectively. CONCLUSIONS: Arthrodesis of the knee joint causes significant kinematic changes in gait pattern,and patients achieve poor results in subjective and functional outcomes(SF- 36, LEFS).Arthrodesis ensures that the extremities are preserved and can enable walking, but it must be viewed as a severe handicap for the patient.

Feasibility, safety, and functional outcomes using the neurological controlled Hybrid Assistive Limb exoskeleton (HAL®) following acute incomplete and complete spinal cord injury - Results of 50 patients.

OBJECTIVE: Recent studies reveal that Hybrid Assistive Limb (HAL®) locomotion training in paraplegic patients suffering from chronic spinal cord injury (SCI) induces improvements in functional and ambulatory mobility. The purpose of this study was to determine the safety, feasibility, and functional effectiveness of HAL® locomotion training in the initial rehabilitation of acute SCI patients. This clinical trial represents the first systematic intervention worldwide for acute SCI patients using a neurologically controlled exoskeleton. DESIGN: Single center, prospective study. SETTING: BG University Hospital Bergmannsheil, Bochum, Germany. PARTICIPANTS: Fifty acute SCI patients (14 women, 36 men). INTERVENTIONS: All participants received a daily (5 times/week) HAL® exoskeleton supported training for 12 weeks (mean amount of training sessions 60.4 ± 30.08). OUTCOME MEASURES: Functional outcome for overground walking was monitored using the 10-m-walk test (10 MWT) combined with the WISCI II score, 6-minute-walk test (6 MWT) and the timed-up and go test (TUG test). Treadmill-related parameters (speed, distance and walking time) and the Lower Extremity Motor Score (LEMS) were recorded separately. RESULTS: Significant improvements were observed for HAL®-associated (walking time, distance and speed) and for functional outcomes (10 MWT, 6 MWT and TUG-test). WISCI-II-Score and the LEMS increased significantly compared with the status prior to training. CONCLUSION: HAL® locomotion training is feasible and safe in the rehabilitation of acute SCI patients. The HAL® exoskeleton enables the patient to perform effective treadmill training and leads to improvements in functional and ambulatory mobility. However, spontaneous recovery vs training-related effects remain unclear and findings should not be extrapolated beyond the acute in-patient rehabilitation setting.Trial registration: German Clinical Trials Register identifier: DRKS00010250..

Influence of Locomotion Therapy With the Wearable Cyborg HAL on Bladder and Bowel Function in Acute and Chronic SCI Patients.

STUDY DESIGN: Retrospective survey. OBJECTIVES: Purpose of this study was to explore whether bowel and bladder management can be influenced by locomotion therapy with HAL Robot Suit. METHODS: 35 subjects with acute (< one year since injury, n = 13) or chronic (> one year since injury, n = 22) incomplete paraplegia (American Spinal Injury Association Impairment Scale (AIS) B, n = 1 / AIS C, n = 22 / AIS D, n = 7) or complete paraplegia (AIS A, n = 5) with zones of partial preservation (ZPP) participated. A retrospective survey was carried out asking for bowel incontinence (Wexner Score), constipation (Cleveland Clinic Constipation Scoring System (CCCS)) and bladder function (self-developed questionnaire) before and after completing a training period of 12 weeks with HAL. RESULTS: Wexner Score over all patients and for group of chronic patients decreased significantly. For group of acute patients Wexner Score decreased insignificantly. Patients from both groups with higher baseline scores could decrease significantly. CCCS was insignificantly reduced for all patients, group of acute and group of chronic patients. For subgroup of chronic patients with higher baseline scores, CCCS decreased at end of training period missing out significance. The self-developed questionnaire showed an improvement in bladder function in 28.24% of all patients, 31.43% of chronic patients, and 23.08% of acute patients. CONCLUSIONS: Our findings show trends of enhanced bladder and bowel function following exoskeleton training. Patients with higher baseline scores in Wexner Score and CCCS seem to benefit more than those with mild to moderate scores.

[New technologies and robotics]. / Neue Technologien und Robotik.

The development of increasingly more complex computer and electromotor technologies enables the increasing use and expansion of robot-assisted systems in trauma surgery rehabilitation; however, the currently available devices are rarely comprehensively applied but are often used within pilot projects and studies. Different technological approaches, such as exoskeletal systems, functional electrical stimulation, soft robotics, neurorobotics and brain-machine interfaces are used and combined to read and process the communication between, e.g., residual musculature or brain waves, to transfer them to the executing device and to enable the desired execution.Currently, the greatest amount of evidence exists for the use of exoskeletal systems with different modes of action in the context of gait and stance rehabilitation in paraplegic patients; however, their use also plays a role in the rehabilitation of fractures close to the hip joint and endoprosthetic care. So-called single joint systems are also being tested in the rehabilitation of functionally impaired extremities, e.g., after knee prosthesis implantation. At this point, however, the current data situation is still too limited to be able to make a clear statement about the use of these technologies in the trauma surgery "core business" of rehabilitation after fractures and other joint injuries.For rehabilitation after limb amputation, in addition to the further development of myoelectric prostheses, the current development of "sentient" prostheses is of great interest. The use of 3D printing also plays a role in the production of individualized devices.Due to the current progress of artificial intelligence in all fields, ground-breaking further developments and widespread application possibilities in the rehabilitation of trauma patients are to be expected.

Rehabilitation during early postoperative period following total knee arthroplasty using single-joint hybrid assistive limb as new therapy device: a randomized, controlled clinical pilot study.

INTRODUCTION: The first weeks after total knee arthroplasty (TKA) are crucial for the functional outcome. To improve knee mobility, a continuous passive motion (CPM) motor rail is commonly used during in-hospital rehabilitation. The single-joint hybrid assistive limb (HAL-SJ) is a new therapy device. The aim of the study was to improve patients' range of motion (ROM), mobility, and satisfaction using the active-assistive support of the HAL-SJ. MATERIALS AND METHODS: Between 09/2017 and 10/2020, 34 patients, who underwent TKA and matched the inclusion criteria, were randomized into study (HAL-SJ) and control (CPM) group. Treatment began after drain removal and was carried out until discharge. Primary outcome parameters were raised pre- and postoperatively and included the Oxford knee score (OKS), visual analog scale (VAS), and acquired range of motion. Furthermore complications caused by the device were recorded. RESULTS: OKS increased in both groups postoperatively, but only significantly in the HAL-SJ group. Postoperative pain improved in both groups without significant differences. Flexion improvement was significant in both groups between days 3/7 and 8 weeks postoperatively. We did not encounter any complications related to HAL-SJ. CONCLUSIONS: In conclusion, use of the HAL-SJ during rehabilitation in the early postoperative period after TKA was safe without disadvantages compared to the control group and seems to have advantages in terms of daily life impairment.

Rehabilitation of Acute Vs. Chronic Patients With Spinal Cord Injury With a Neurologically Controlled Hybrid Assistive Limb Exoskeleton: Is There a Difference in Outcome?

This study aimed to assess the outcome of acute and chronic participants with spinal cord injury (SCI) after 12 weeks of bodyweight supported treadmill training (BWSTT) with a hybrid assistive limb exoskeleton (HAL). Acute participants were defined as ≤12 months between SCI and training, chronic participants >12 months between SCI and training. We assessed whether HAL-assisted BWSTT is advantageous for acute and chronic participants and if length of time post injury impacts the outcome of HAL-assisted BWSTT. As the primary outcome, we assessed the time needed for the 10 meter walk test (10MWT). Hundred and twenty-one individuals participated in a 12-week HAL-assisted BWSTT five times a week. We regularly conducted a 10MWT, a 6 minute walk test (6MWT), and assessed the walking index for spinal cord injury (WISCI II) and lower extremity motor score (LEMS) to evaluate the gait performance without the exoskeleton. Distance and time were recorded by the treadmill while the participant was walking with the exoskeleton. All participants benefit from the 12-week HAL-assisted BWSTT. A significant difference between acute and chronic participants' outcomes was found in 6MWT, LEMS, and WISCI II, though not in 10MWT. Although chronic participants improved significantly lesser than acute participants, they did improve their outcome significantly compared to the beginning. Hybrid assistive limb-assisted BWSTT in the rehabilitation of patients with SCI is advantageous for both acute and chronic patients. We could not define a time related cut-off threshold following SCI for effectiveness of HAL-assisted BWSTT.

Influence of an on-body lifting aid (HAL® for Care Support) on kinematics during repetitive lifting in healthy men.

Work-related lower back pain (LBP) leads to socio-economic burden and demands solutions. The hybrid assistive limb (HAL) for Care Support (Cyberdyne Inc., Ibaraki, Japan) is an active on-body lifting aid to assist joint motion according to the wearer's voluntary motor drive to reduce the lumbar load. A few studies investigated HAL and stated efficacy in terms of enhanced performance and reduced fatigue, yet the question remained if the use of HAL may result in a different execution of movement, for example by influencing the kinematics of the lower extremities. The aim of this study was to determine the influence of HAL on kinematics of the lower limbs and the spinal column during repetitive freestyle symmetrical lifting. Kinematic data was recorded by an inertial measurement unit sensor system in 11 healthy men lifting and lowering a 19.5 kg barbell under three conditions (no HAL, HAL Level 3/5, HAL Level 5/5). Outcome parameters were maximum and minimum angles as well as range of motion (ROM) of thoracic spine, lumbar spine, hip- and knee joint in sagittal plane. We found a significantly decreased ROM of the lumbar spine as well as a significantly reduced maximum and minimum thorax extension when starting lifting and in upright position after lifting, respectively, while using HAL. Influence of HAL on the kinematics of the lower limbs was not significant. Differences between both evaluated HAL conditions were not significant. This study proved limited lumbar spine ROM and reduced thorax extension without alterations of lower limbs kinematics when using HAL. This might potentially decrease the risk of work-related LBP.

Improved Physiological Gait in Acute and Chronic SCI Patients After Training With Wearable Cyborg Hybrid Assistive Limb.

In recent years robotic devices became part of rehabilitation offers for patients suffering from Spinal Cord Injury (SCI) and other diseases. Most scientific publications about such devices focus on functional outcome. The aim of this study was to verify whether an improvement in physiological gait can be demonstrated in addition to the functional parameters after treatment with neurological controlled HAL® Robot Suit. Fifteen subjects with acute (<12 months since injury, n = 5) or chronic (>12 months since injury, n = 10) incomplete paraplegia (AIS B, n = 0/AIS C, n = 2/AIS D, n = 8) or complete paraplegia (AIS A, n = 5) with zones of partial preservation participated. Subjects underwent a body weight supported treadmill training for five times a week over 12 weeks using HAL®. At baseline and at the end of the study a gait analysis was performed and additional functional parameters such as 10-Meter-Walk-Test, Timed-Up-and-Go-Test, 6-Minutes-Walk-Test, and WISCI II score were collected. Results were evaluated for whole group and individually for acute and chronic subgroups. All functional parameters improved. Differences were also found in physiological parameters such as phases of gait cycle and accompanied by significant improvement in all spatiotemporal and gait phase parameters. The presented study shows signs that an improvement in physiological gait can be achieved in addition to improved functional parameters in patients with SCI after completing 12-week training with HAL®. Trial Registration: DRKS, DRKS00020805. Registered 12 February 2020-Retrospectively registered, https://www.drks.de/DRKS00020805.

Long-term follow up of extensor tendon ruptures of the knee using electromyography and three-dimensional gait analysis.

BACKGROUND: The aim of this study was to analyze the long-term outcomes of extensor tendon ruptures of the knee using exact measuring tools. METHODS: The results of patients treated for extensor tendon rupture with a minimum follow up of 10 years were reviewed. Electromyography (EMG) and three-dimensional (3D) gait analyses were performed and compared with the healthy side of each patient and with the gait patterns of 20 healthy controls. Functional outcome scores were assessed using the Lysholm score and Knee Injury and Osteoarthritis Outcome Score (KOOS). RESULTS: After a mean of 13.4 ± 3 years, 23 patients were available for follow up. The mean Lysholm score was 86.6, and the KOOS averaged 78.1. Gait analysis showed no major kinematic differences between these patients compared with healthy controls. In the squat test, the mean peak amplitude of the rectus femoris muscle was significantly smaller on the injured side than on the healthy side (140.21 ± 66.13 µV vs. 168.25 ± 91.77 µV; P = 0.01). The mean peaks of the vastus lateralis and medialis EMG signals were also lower on the injured side (P = 0.63; P = 0.08). Correspondingly, the thigh girth at 20 cm and 10 cm above the knee was significantly lower on the injured side. One patient had re-rupture after patella tendon repair. CONCLUSION: At long-term follow up the patients reached good clinical outcomes and exhibited mainly physiological gait patterns after rupture of knee extensor tendons. However, the thigh muscles showed hypotrophy and a significantly smaller EMG signal amplitude during a high-intensity task on the formerly injured side.

Effectiveness of an on-body lifting aid (HAL® for care support) to reduce lower back muscle activity during repetitive lifting tasks.

The Hybrid Assistive Limb Lumbar Type (HAL) is an active exoskeleton that provides motion according to the wearer's voluntary drive. It was developed to support back muscles during repetitive lifting tasks. The purpose of this paper was to determine if the myoelectric activity of the back muscles is reduced or altered when using the HAL and to investigate a possible influence of its use on the cardiovascular system. Fourteen healthy young men without lower back pain underwent a freestyle, symmetrical-lifting protocol. Participants lifted a 17.05 kg handled-box for 10 min. with and without HAL support. Surface electromyography (sEMG) signals were recorded at thoracic (TES) and lumbar erector spinae (LES) and quadriceps femoris (QF). Heart rate was recorded from electrocardiogram. The subjects rated their level of physical exertion using the Borg Rating of Perceived Exertion (BORG) scale. Additionally they commented on sites of discomfort, perceptions of force, and loss of range of motion. The root mean square and integrated sEMG value was significantly reduced at the LES and TES. Heart rate variability output variables did not show any significant difference. The BORG-Scale showed no difference, with a mean score of 2.5. The HAL decreased the magnitude and onset of muscle activity and force in the lower back in a repetitive lifting task. Reduction of the muscle force and activity required during the lifting process is meaningful regarding lower back pain prevention, and the HAL may contribute to reducing the incidence of lower back pain in the working population.