International Recommendations to Manage Poststroke Equinovarus Foot Deformity Validated by a Panel of Experts Using Delphi.

OBJECTIVE: To establish international recommendations for the management of spastic equinovarus foot deformity. DESIGN: Delphi method. SETTING: International study. PARTICIPANTS: A total of 24 international experts (N=24) in neuro-orthopedic deformities, from different specialties (Physical and Rehabilitation Medicine physicians, neurologists, geriatricians, orthopedic surgeons, neurosurgeons, plastic surgeons). INTERVENTIONS: Experts answered 3 rounds of questions related to important aspects of diagnosis, assessment, and treatment of spastic equinovarus foot deformity. MAIN OUTCOME MEASURES: A consensus was established when at least 80% of experts agreed on a statement RESULTS: A total of 52 items reached consensus. Experts recommend assessing effect of the deformity on functional activities before treatment. Before treatment, it is crucial to differentiate spastic muscle overactivity from soft tissue contractures, identify which muscles are involved in the deformity, and evaluate the activity of antagonist muscles. Motor nerve blocks, 2-dimensional video analysis, and radiologic examinations are often required to complement a clinical examination. The treatment of equinovarus foot depends on the correctability of the deformity and the patient's ability to stand or walk. The preoperative assessment should include an interdisciplinary consultation that must finalize a formal agreement between physicians and the patient, which will define personalized attainable goals before surgery. CONCLUSION: The establishment of guidelines on managing equinovarus foot will help physicians and surgeons, specialists, and nonspecialists to diagnoses and assess the deformity and direct patients to a network of experts to optimize patient functional recovery and improve their autonomy.

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.

Heterotopic ossification of the shoulder in patients with traumatic brain injury.

BACKGROUND: We retrospectively reviewed 10 consecutive patients (11 shoulders) with traumatic brain injury who underwent surgical resection of heterotopic ossification (HO) of the shoulder. Our primary research goal was to determine the change in range of motion (ROM) at the shoulder after resection of heterotopic ossification in patients with traumatic brain injury. Secondary research goals were to determine simple functional outcome gains related to activities of daily living and to determine complications in this patient cohort. METHODS AND MATERIALS: Data were collected retrospectively and included measured ROM of the shoulder and observed ability to perform daily activities. The average age of the patients was 33 years (range, 20 -45). RESULTS: Sagittal plane motion (flexion/extension) increased by 85.0°, coronal plane motion (adduction/abduction) increased by 59.1°, and axial plane motion (internal/external rotation) increased by 66.8° (P < .001). Nine patients increased independence with improved functional status (7 patients able to perform all 3 activities of feeding, grooming, and toiletry) (P < .001). CONCLUSION: Surgical resection of heterotopic ossification of the shoulder is an effective procedure to increase joint mobility and improve function.

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.

Outcomes of tendon fractional lengthenings to improve shoulder function in patients with spastic hemiparesis.

BACKGROUND: Patients with spastic hemiparesis after upper motor neuron (UMN) injury often exhibit limited shoulder movement. We evaluated the outcomes of shoulder tendon fractional lengthenings in patients with spasticity and preserved volitional control. METHODS: A consecutive series of 34 adults with spastic hemiparesis from UMN injury (23 post-stroke, 11 post-traumatic brain injury) and limited shoulder movement with preserved volitional motor control who underwent shoulder tendon fractional lengthenings (pectoralis major, latissimus dorsi, teres major) were evaluated. Active and passive shoulder motion, spasticity, pain, and satisfaction were considered pre- and postoperatively. RESULTS: There were 15 males and 19 females with a mean age of 44.1 years. Mean follow-up was 12.2 months. Mean Modified Ashworth spasticity score was 2.4 preoperatively compared to 1.9 postoperatively (P = .001). Active flexion, abduction, and external rotation improved compared to the normal contralateral side (P < .001) with most dramatic gains in external rotation. Similarly, passive extension, flexion, abduction, and external rotation improved compared to the normal contralateral side (P < .01). Ninety-four percent (15/16) with preoperative pain had improved pain relief postoperatively with 14 (88%) being pain-free. Thirty-one (92%) were satisfied with the outcome. CONCLUSION: Shoulder tendon lengthenings can be an effective means of pain-relief, improved motion, enhanced active motor function, and decreased spasticity in patients with spastic hemiparesis from UMN injury.

Surgical resection of heterotopic bone about the elbow: an institutional experience with traumatic and neurologic etiologies.

PURPOSE: We evaluated the outcomes of patients with elbow heterotopic ossification (HO) who underwent surgical intervention. Our goal was to elucidate differences in outcome of surgical treatment between those patients with traumatic brain injury, direct elbow trauma, or combined etiologies. In addition, we used regression analysis to adjust for confounding factors (such as age, gender, preoperative range of motion [ROM], location of HO, chronicity of HO [ie, time from HO formation to surgery], and whether motor control was spastic or normal) on the relationship between surgical outcome and etiology. METHODS: We reviewed 60 patients (64 elbows) surgically treated for heterotopic ossification. A total of 42 patients had trauma as the primary etiology, 15 had traumatic brain injury, and 7 had combined etiologies. All had pain or functional limitations at presentation. All patients had surgical resection of their HO. Functional and ROM outcomes were recorded. RESULTS: Mean preoperative arc of motion for the entire cohort was 57° (range, 0° to 150°). Mean postoperative arc for the entire cohort was 106° (range, 0° to 145°) at a mean follow-up of 44 months (range, 21-72 mo), demonstrating a significant gain. Average gain, in arc of motion was 49° (range, 10° to 140°). Gains in motion were not significantly different in any individual etiologic group. A total of 6% of cases were complicated by infection, 13% of cases had recurrence of HO, and 11% of cases required repeat surgery for infection or recurrence. Preoperative ROM was an important independent predictor of final range achieved and gain in ROM after surgical intervention. Recurrence rates were higher in patients with neurologic involvement. Postoperative stiffness was related to preoperative stiffness, delay of surgery longer than 12 months, and anterior location of the HO. CONCLUSIONS: Surgical excision of heterotopic bone about the elbow results in significant gains in ROM regardless of etiology. The likelihood of recurrence is higher in patients with central nervous system injuries than in patients with purely localized trauma.

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.

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.

Heterotopic ossification following traumatic brain injury and spinal cord injury.

Heterotopic ossification associated with neurologic injury, or neurogenic heterotopic ossification, tends to form at major synovial joints surrounded by spastic muscles. It is commonly associated with traumatic brain or spinal cord injury and with other causes of upper motor neuron lesions. Heterotopic ossification can result in a variety of complications, including nerve impingement, joint ankylosis, complex regional pain syndrome, osteoporosis, and soft-tissue infection. The associated decline in range of motion may greatly limit activities of daily living, such as positioning and transferring and maintenance of hygiene, thereby adversely affecting quality of life. Management of heterotopic ossification is aimed at limiting its progression and maximizing function of the affected joint. Nonsurgical treatment is appropriate for early heterotopic ossification; however, surgical excision should be considered in cases of joint ankylosis or significantly decreased range of motion before complications arise. Patient selection, timing of excision, and postoperative prophylaxis are important components of proper management.

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.

Validation of Adult Relative Radiation Levels Using the ACR Dose Index Registry: Report of the ACR Appropriateness Criteria Radiation Exposure Subcommittee.

The ACR Dose Index Registry (DIR) provides a new source of clinical radiation exposure data that has not been used previously to establish or update the relative radiation level (RRL) values in the ACR Appropriateness Criteria (AC). The results of a recent review of DIR data for 10 common CT examinations were compared with current ACR AC RRL values for the same procedures. The AC RRL values were previously determined by consensus of members of the AC Radiation Exposure Subcommittee based on reference radiation dose values from the literature (when available) and anecdotal information from individual members' clinical practices and experiences. For 7 of the 10 examination types reviewed, DIR data agreed with existing RRL values. For 3 of 10 examination types, DIR data reflected lower dose values than currently rated in the AC. The Radiation Exposure Subcommittee will revise these RRL assignments in a forthcoming update to the AC (in October 2018) and will continue to monitor the DIR and associated reviews and analyses to refine RRL assignments for additional examination types. Given recent attention and efforts to reduce radiation exposure in CT and other imaging modalities, it is likely that other examination types will require revision of RRL assignments once information from the DIR database is considered.

Actual and perceived activity levels in polio survivors and older controls: a longitudinal study.

OBJECTIVE: To examine factors associated with daily step activity, perceived activity, maximum walking speed, and walking speed reserve over time in polio survivors and older adults with no history of polio. DESIGN: Longitudinal study. SETTING: A research clinic and the community. PARTICIPANTS: Polio survivors (n=96; 65 in postpolio syndrome [PPS] group, 31 in non-PPS group) and older adults (n=112) with no history of polio. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Daily step activity, perceived activity, maximum walking speed, and walking speed reserve. RESULTS: Results showed decreases in perceived activity over time in the PPS group. However, there was no change in average daily walking activity. Overall, polio survivors walk less and have a smaller walking speed reserve than controls. Knee strength was positively associated with maximum walking speed and walking speed reserve in all groups. Weight and age were associated with daily step activity in controls but not polio survivors. CONCLUSIONS: Daily walking activity did not change statistically over the 3-year study period, although perceived activity and the walking speed reserve decreased among polio survivors with PPS. On average, polio survivors appear to function with minimal functional reserve, as their preferred walking speed was close to their maximum speed.

Surgery can reduce the nonoperative care associated with an equinovarus foot deformity.

UNLABELLED: Equinovarus is the most common lower extremity deformity seen after a stroke. Despite its frequency, there are no specific guidelines in determining when surgery should be considered and for which patients it is appropriate. We evaluated the charges of nonsurgical and surgical treatments for equinovarus foot in 29 consecutive patients who underwent surgery for a unilateral equinovarus deformity after stroke. Twenty-six patients (seven males, 19 females) were available for followup. Mean patient age at the time of stroke was 48.2 years (range, 3-66 years). The average age at surgery was 54.7 years (range, 23-72 years), with a mean duration of nonsurgical treatment of 74.7 months. The minimum followup was 6 months following surgery (mean, 18.2 months; range, 6-48 months). Physical therapy accounted for 88% of nonoperative charges, with chemodenervation and orthotics accounting for 10% and 2%, respectively. Postoperatively, 19 patients were able to discontinue physical therapy compared with none preoperatively, and 17 discontinued orthotic use. Surgical correction of the equinovarus foot, in the appropriate patient, can decrease the use of nonoperative care for a patient who has had a stroke. We recommend surgery be considered earlier when an equinovarus deformity persists after the period of spontaneous neurologic recovery. LEVEL OF EVIDENCE: Level III, therapeutic study.

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.

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.

Sexual dimorphism in stroke.

Stroke is a leading cause of death and serious, long-term disability. Studies evaluating differences between men and women are lacking. Significant differences exist between men and women in terms of risk factors and susceptibility to stroke. Women are less likely to have diagnostic studies performed to evaluate their risk for stroke, and they have a higher mortality following acute stroke. Women however, have a higher rate of arterial recanalization after intravenous tissue plasminogen activator used for the treatment of acute stroke. The data comparing the effectiveness of treatments for prevention of recurrent stroke between men and women is sparse. There have not been any studies comparing results of treatment of musculoskeletal impairments in men and women after stroke.