Upper limb surgery for tetraplegia: assessment of a 10-point strategy.

PURPOSE: Palliative motor surgery of the tetraplegic upper limb is well-defined, with relatively precise indications that however vary somewhat from team to team. Our personal indications originated mainly from Zancolli, and were applied by the same surgeon in two independent rehabilitation centers. The goals of this study were to assess the application of these indications with time. METHODS: Our retrospective study included three parts: summarization of our initial indications into a 10-point reference strategy; gathering the medical records related to all of the tetraplegic upper limb operations from 1989 to 2006, except for those related to complications and/or salvage procedures. For each patient, collected data corresponded to the 10 strategic points (SP); comparison of the collected data with the reference strategy, upper limb by upper limb, point by point, in order to identify and document any deviations. RESULTS: We assessed the use of the reference strategy in 272 consecutive operations (139 upper limbs, 96 patients). Overall nonconformity rate with the use of the 10-point strategy was 27% (38/139). Except for one very atypical case, all of the exceptions from the reference strategy were due to specific anatomical or physiological conditions. CONCLUSIONS: Our reference strategy has remained noticeably stable over time. However, three important evolutionary modifications occurred: systematic choice of biceps instead of deltoid to restore elbow extension; addition of the split distal flexor pollicis longus tenodesis procedure; and removal of extensor carpi radialis brevis from the list of potential flexor pollicis longus motors. Two issues, dealing with the systematic use of lassos and with brachio radialis to extensor digitorum communis transfer, are likely to be revisited in the future.

[Satisfaction with technological equipment in individuals with tetraplegia following spinal cord injury]. / Enquête de satisfaction sur l'équipement technologique des personnes tétraplégiques par blessure medullaire.

OBJECTIVE: To measure the acquisition, use and satisfaction with high technology equipment by spinal cord injured tetraplegic subjects. DESIGN AND SETTING: A questionnaire was mailed to 102 tetraplegic subjects who were hospitalised in the rehabilitation center of Kerpape (Ploemeur, France) between 1998 and 2004, and 59 subjects responded. The questionnaire asked about the use of telephones, computers, wheelchairs and environmental controls at home. RESULTS: When a piece of equipment was acquired, it was very often used. Patient satisfaction with equipment was 79.3%. Home phones and mobile phones were often used with options such as hands-free devices (78 and 59% respectively). A total of 64.4% of subjects acquired a manual wheelchair and 61% a power wheelchair. The most commonly acquired options on the power wheelchairs were the powered recline (73,7%) and tilt (71,1%) systems. All options were used but all were more desired than acquired. A total of 27.1% of subjects desired a pushrim-activated power-assist wheelchair, but only 15.3% had acquired one; 695% of subjects had a computer. Communication was the first use for the computer (82.5%); 49.2% of subjects had acquired an environmental control system, but 20% desired one. The first reason for lack of acquisition was financial difficulties but also accessibility and information problems. The factor that influenced the acquisition and need for equipment was the degree of spinal cord injury. No other factor reduced patient satisfaction with equipment. CONCLUSION: Patients were satisfied with the equipment they acquired. But their needs, especially wheelchair options and environmental control systems, were not satisfied.

[Extensor tenodesis to the retinaculum extensorum: anatomic and biomechanical study]. / Ténodèse des extenseurs sur le retinaculum extensorum: étude anatomique et biomécanique.

INTRODUCTION: The extensor tenodesis is a direct dynamic tenodesis which is activated by wrist flexion due either to hand weight or flexor carpi radialis. This tenodesis is usually performed to the distal radius, but it is possible to fix EDC (extensor digitorum communis) to the retinaculum extensorum. MATERIAL AND METHODS: Biomechanical study concerned 12 anatomical subjects (24 wrists). The biometric and radiological analysis of retinaculum displacement distalwards was made under low (1 kg) and moderate (6 kg) pulling. Surgical clips were placed on the proximal and distal limits of the retinaculum in order to study their positions on roentgenograms. RESULTS: Average width of the retinaculum was 19 mm. Average movement under 1 kg drive was 6 mm and 8.6 mm under 6 kg drive. X-rays showed that the proximal border of the retinaculum was always located proximally to the wrist rotate centre, whatever the traction. DISCUSSION: We found the same anatomical features described by different authors, except for the width of the retinaculum. Our study suggests that the retinaculum is strong enough to support a surgical tenodesis.

[Cup and cone arthrodesis of the thumb in palliative surgery for tetraplegia. Retrospective study of 57 cases]. / Arthrodèse cône-cupule des articulations du pouce dans la chirurgie palliative du tétraplégique. Etude rétrospective de 57 cas.

INTRODUCTION: The cup and cone technique, first described by Carrol and Hill is very simple. It affords excellent contact between bones, and allows all possible adjustments of the arthrodesis in three planes before its final fixation. MATERIAL AND METHODS: Fifty seven cup and cone arthrodesis of the thumb were performed in 41 adult tetraplegic patients. Level of arthrodesis was i.p. in 28 cases, TM in 25 cases and MP in 4 cases. Distribution in Giens classification was 3 group 1, 14 group 2, 9 group 3, 23 group 5, 2 group 6, 1 group 7, 2 group 10. Mean follow-up was 51 months. Three criteria were retrospectively studied: the clinical strength of arthrodesis, its position, and the potential existence of complications. RESULTS: Clinical fusion was obtained in 8 week in all cases, without any infection. No delayed union was observed. In only one case, a surgical revision was required, due to initial bad setting of TM arthrodesis and an intermetacarpal arthrodesis was performed with a bony graft. In all other cases, position of arthrodesis was correct. In a few cases, only minor or non specific drawbacks were observed: TM arthrodesis were sometimes painful during the first 6 months postoperatively; transient dystrophy of the thumb nail occurred two times in i.p. arthrodesis; the worst drawback was the shortening of the thumb, which impaired the key-grip in cases where the thumb was preoperatively short. DISCUSSION: In tetraplegic patients, stabilization of the thumb can be obtained either by split distal FPL tenodesis or by an arthrodesis at TM, MP or i.p. level of the thumb. When the provided thumb length is adequate arthrodesis is preferred. The cup and cone technique is very simple and effective. It is fit particularly in tertraplegic patients, whatever the level of the thumb arthrodesis.

[Prevalance of nosocomial infections in tetraplegic upper extremity surgery. Prospective study of twenty patients]. / Prévalence des infections nosocomiales dans la chirurgie du membre supérieur des tétraplégiques. Etude prospective de vingt patients.

INTRODUCTION: Many risk factors of nosocomial infection may be met with tetraplegic patients. The objective of this work was to study the prevalence of colonization by 3 multiresistants bacteria (methicillin resistant staphylococcus aureus (MRSA), Klebsiella pneumoniae with widened spectrum beta lactamase or multi-resistant Acinetobacter baumannii) on this population. MATERIAL AND METHODS: It was about a prospective study for which we included 20 consecutive patients coming from a rehabilitation of long stay center to have a surgical operation of palliative reanimation of the upper limb. For each patient, the first morning of his hospitalization, many sites cultures were carried out for bacteriological analysis whose results were returned in 48 h to the operator. No patient was excluded. RESULTS: Five patients (25%) showed the presence of SARM. One patient (5%) showed the presence of Klebsiela pneumoniae. One of the patients carrying a SARM was also carrying Acinetobacter baumannii. Overall 6 patients were contaminated (30%) but no postoperative infection occurred, neither at the time of the hospitalization nor after the exit of the service. DISCUSSION: The various risk factors of nosocomial infection appearance met in tetraplegic patient were analyzed. This study showed that the cares of tetraplegic patients limited to the maximum the risk of nosocomial infection appearance (no one in this series) in spite of an important contamination met in this type of population which presents long durations of hospitalization, main risk factor regularly met.

[Effect of brachial-radial and extensor carpi radialis longus tenodesis on elbow flexion-extension movements. Application to tendon transfers in tetraplegia]. / Mesure sur le brachio-radialis et l'extensor carpi radialis longus de l'effet ténodèse lié aux mouvements de flexion-extension du coude. Application aux transferts tendineux chez le tétraplégique.

The authors show that extension of the elbow produces a traction on brachioradialis (BR) and extensor carpi radialis longus (ECRL): if their tendon is distally freed, it is pulled in the proximal direction when the elbow extends. This phenomenon provides tenodesis effects, especially after tendon transfer in tetraplegia. It has been assessed on 31 upper limbs of patients and fresh cadavers. The mean tendon excursion, between 90 degrees flexion and full extension of the elbow, was 32 mm for BR and 19 mm for ECRL. These tenodesis effects related to the extension of the elbow leads the authors to recommend three practices in tetraplegic patients: active extension of the elbow should be restored before rehabilitation of the hand, and a 90 degrees flexion of the elbow is the position in which BR and ECRL transfers should be set intraoperatively, as well as immobilized postoperatively.

[Isokinetic dynamometric evaluation of rehabilitation results of elbow extension in tetraplegic patients]. / Evaluation par dynamomètre isocinétique des résultats de la réanimation de l'extension du coude chez le tétraplégique.

The authors designed a protocol to assess isokinetic muscle strength of elbow in tetraplegic patients after rehabilitation of elbow extension. Twenty-seven elbows from 16 patients were assessed, after deltoïd-to-triceps (10 cases) or biceps to triceps transfer (17 cases); the mean follow-up was 39 months. Seventeen elbows from 9 healthy individuals were also assessed. Regardless of the type of the transfer performed, the extension torque was on average much lower in the group of tetraplegic patients than in the control group, especially at the beginning of the movement. However the dynamic appearance of the curve of torque in extension was similar in the two groups. The mean flexion torque was on average very low after biceps-to-triceps transfer, especially at the end of the movement, but remained acceptable after deltoïd-to-triceps transfer.

Energy consumption of paraplegic locomotion using reciprocating gait orthosis.

The energy cost of walking using a reciprocating gait orthosis (RGOII) with functional electrical stimulation (FES) was assessed in 14 patients with spastic complete paraplegia from six rehabilitation centres. Before and after training asing RGOII with FES, the subjects performed a progressive maximal test on an arm-crank ergometer to obtain their laboratory peak oxygen uptake (LVO2peak), heart rate (HR) and blood lactate concentration changes. At the end of the training session, oxygen uptake (VO2) was measured during a walking test with orthosis at different speeds (6 min steady state at 0.1 m.s-1, followed by 2-min stages at progressively increasing speeds up to exhaustion). Of the subjects 4 repeated this test using orthosis without FES. At a speed of 0.1 m.s-1, VO2 represented 47 (SD 23)% of LVO2peak, mean HR was 137 (SD 21) beats.min-1 and mean blood lactate concentration 2.4. (SD 1.4) mmol.l-1. Maximal speed ranged from 0.23 to 0.5 m.s-1. At maximal speed, VO2 was 91 (SD 18)% of LVO2peak, mean HR reached 96 (SD 7)% and mean blood lactate concentration only 52 (SD 19)% of the maximal values measured during the laboratory test. Walking without electrical stimulation induced an increase in HR but there was no difference in VO2 and blood lactate compared to walking with stimulation. The training period did not result in any improvement in maximal physiological data. We concluded that the free cadence walking speed with orthosis remains much lower than that of able-bodied people or wheelchair users. The metabolic cost at a given speed is much higher even if, using a stimulation device, the cardiovascular stress is reduced.

Restoration of functional gait in paraplegic patients with the RGO-II hybrid orthosis. A multicentre controlled study. I. Clinical evaluation.

By means of a multicentric study in six rehabilitation centres, we assessed the RGO-II orthosis to restore functional gait in patients with spinal cord injuries. The 26 subjects participating in the study had spastic complete paraplegia. Twenty one had progressed to the training programme and 19 were able to stand up alone. The trained subject's walking distance ranged from 200 to 1400 m, while their walking speed ranged from 0.15 to 0.45 ms-1. A 2-month follow-up study revealed that, out of 15 patients using the hybrid orthosis, 11 were home users. Modalities and adverse effects of training are reported. The place of gait restoration with a hybrid orthosis in a rehabilitation programme is discussed.

Restoration of functional gait in paraplegic patients with the RGO-II hybrid orthosis. A multicenter controlled study. II: Physiological evaluation.

We have investigated physiological changes in 21 patients with a spinal cord injury who were fitted with the RGO-II hybrid orthosis. All parameters were measured before and after a training programme in order to evaluate the benefit of gait rehabilitation, cardiovascular adaptation, constipation, spasticity and osteoporosis. A tendency for the improvement in cardiovascular function was noticed, and a segmental decrease in right colonic transit time was observed. However there was no reproducible change in spasticity, and no gain in bone mineral density. These data suggest that the physiological benefits which occur when patients walk with the aid of a hybrid orthosis only correct the effects of immobility. In addition, we did not find any physiological improvement regarding the neurological lesion (spasticity or osteoporosis).

[A variant of island flaps for the covering of pressure sores: the hatchet flap. Apropos of 31 cases]. / Variante des lambeaux en îlot pour couverture d'escarres: le lambeau en hachette. A propos de 31 cas.

The authors propose a modification of the classical design of island flaps for cover of pressure sores, applied to gluteus maximus and tensor fascia lata muscles: the hatchet flap. 31 flaps have been used including 13 gluteus maximus superior flaps for sacral pressure sores, 9 gluteal inferior flaps for ischial pressure sores and 9 tensor fascia lata flaps for trochanteric pressure sores. A small partial necrosis and two cases of sepsis were observed in this series, but did not require surgical revision. The authors emphasize the value of this modification of the classical flap design, which preserves an even better musculocutaneous capital in these patients, who are often already multi-operated. The very rapid recovery of patients supports the authors' application of hatchet flaps to the surgery of pressure sores, and suggests the extension to other musculocutaneous flaps in the future.