Outcomes of Below-the-Knee Amputations for Chronic Lower Extremity Pain.

The study evaluated the physical,mental, and functional outcomes following below-the-knee amputation (BKA) for management of chronic, debilitating lower extremity pain. The hypothesis was that patients who undergo a BKA to alleviate chronic pain achieve a greater level of function, experience decreased pain, and benefit from improved health-related quality of life. Patients who received a BKA attended an orthopaedic clinic and completed questionnaires examining their overall health, functional status, mental health, and pain. Thirty-seven patients were identified as eligible for study participation; 15 agreed to participate. Although most participants continued to experience pain in their residual limb after BKA, they reported their pain decreased to a manageable level. Participants experienced a statistically significant improvement in their perceived physical health. The authors believe a BKA for chronic pain is a reasonable treatment option for patients who continue to experience lower extremity pain after failed medical and surgical management of chronic pain. (Journal of Surgical Orthopaedic Advances 26(4):200-205, 2017).

Upper extremity spasticity in children with cerebral palsy: a randomized, double-blind, placebo-controlled study of the short-term outcomes of treatment with botulinum A toxin.

PURPOSE: Botulinum A toxin (BoNT-A) injections are used widely to manage lower extremity spasticity in children with cerebral palsy. However, their use in the upper extremity is less well defined. This randomized, double-blind, placebo-controlled clinical trial evaluated the safety and efficacy of upper extremity intramuscular injections of BoNT-A in a cross-section of children with varying levels of function. METHODS: Upper extremity function of study participants (N = 73; M:F = 47:26; age range, 3-18 y) was evaluated using the House Classification system (scores, 0-8, where a higher score indicates higher functional ability). Three groups of children were identified based on their House scores: 0-2 (n = 10), 3-5 (n = 54), and 6-8 (n = 9). Following randomization, children received a BoNT-A or placebo injection at baseline. Injections were administered at 8 and 20 weeks if clinically indicated. Occupational therapists evaluated study participants at screening, at baseline, and at 4, 8, 14, 20, and 26 weeks. Physician evaluations occurred at baseline and at 8, 20, and 26 weeks. The Melbourne Assessment of Unilateral Upper Limb Function evaluated the quality of upper extremity function before and after injections and served as the primary outcome variable. RESULTS: The majority of study participants underwent 3 injection sessions. Muscles injected were individualized based on each child's particular spasticity pattern. A statistically higher percentage of children receiving BoNT-A injections showed an improvement in the Melbourne assessment at 26 weeks compared with the children receiving placebo. The range, frequency, and severity of postinjection adverse events were similar in both groups. CONCLUSIONS: Children receiving BoNT-A injections demonstrated clinically meaningful short-term improvements in upper extremity function. Injections were well tolerated and safe. In contrast to other studies, study participants underwent multiple injection sessions based on their individual spasticity patterns.

Quantification of upper extremity function and range of motion in children with cerebral palsy.

This study evaluated the hypothesis that upper extremity function and range of motion can be quantified reliably in children with cerebral palsy (CP) in a busy clinical setting. The specific aim was to determine the inter- and intrarater reliability of a modified House Functional Classification (MHC) system to evaluate upper extremity function and a standardized instrument to document upper extremity range of motion (Upper Extremity Rating Scale [UERS]). Sixty-five children with CP (43 males, 22 females, mean age 9y 2mo, SD 4y 1mo) with spasticity involving the upper extremity (quadriplegia n=22; hemiplegia n=36; diplegia n=7; Gross Motor Functional Classification System Levels I n=41, II n=6, III n=3, IV n=5, V n=10) were evaluated independently by occupational therapists and orthopedic surgeons using both instruments at several visits. Inter- and intrarater reliability were determined for both instruments by calculating measures of agreement (weighted kappa values and intraclass correlation coefficients [ICCs]). Interrater agreement (ICC=0.94) and intrarater agreement (ICC=0.96) on the MHC were good to excellent. Similarly, inter-rater agreement (kappa 0.66-0.81) and intrarater agreement (kappa 0.64-0.88) on the UERS was either good or excellent. The MHC and the UERS provide standardized, reliable, reproducible, and efficient instruments that can be used by occupational therapists and orthopedic surgeons to evaluate the upper extremities of children with CP.

Bioprotection of tendon repair: adjunctive use of botulinum toxin A in Achilles tendon repair in the rat.

BACKGROUND: Tendon-repair techniques have evolved to increase the construct strength of the repair site in order to permit early active range of motion without tendon gap or rupture. The present study evaluated the hypothesis that the injection of botulinum neurotoxin type-A (BoNT-A) into the gastrocnemius muscle will reduce the active force production of that muscle below the force required to rupture the associated, repaired Achilles tendon. METHODS: Seventy-nine rat Achilles tendons were surgically bisected and were repaired with use of a two-strand core suture with a running epitenon repair. After the repair, the animals were treated with unilateral intramuscular (gastrocnemius) injections of either BoNT-A (6 U/kg body weight) (thirty-seven rats) or saline solution (forty-two rats). Operatively treated ankles were fixed in the neutral position with a percutaneous pin for the first two days after surgery. Unrestricted ankle motion and weight-bearing were allowed after the second postoperative day. An assessment of gap formation or rupture at the repair site, electrophysiologic measurements of force applied to the tendon, and an assessment of the strength of the repaired tendon were performed. RESULTS: Intramuscular BoNT-A injections produced a significant, reversible reduction in active muscle force (p < 0.007). Twitch and tetanus contractions decreased to approximately 25% of the values for the control side within one week, remained at <50% of the values for the control side at one month, and returned to normal levels by six months. The tetanic force capability of the muscles that had been injected with BoNT-A was fivefold to tenfold less than the force required to rupture the associated Achilles tendon for as long as four weeks after tendon repair. The spontaneous Achilles tendon rupture rate of repaired tendons in the BoNT-A group was three times lower than that in the saline solution group at one week, and the tendon rupture force was significantly higher in the BoNT-A group between one and three weeks after repair (p < 0.007). There was no significant difference in tendon rupture force between the two groups after three weeks. CONCLUSIONS: Intramuscular gastrocnemius BoNT-A injections were associated with a significant reduction in force-generating potential, such that the muscle was incapable of actively producing enough force to rupture the repaired Achilles tendon in this rat model of tendon repair.

Cerebral palsy.

Cerebral palsy, a range of non-progressive syndromes of posture and motor impairment, is a common cause of disability in childhood. The disorder results from various insults to different areas within the developing nervous system, which partly explains the variability of clinical findings. Management options include physiotherapy, occupational and speech therapy, orthotics, device-assisted modalities, pharmacological intervention, and orthopaedic and neurosurgical procedures. Since 1980, modification of spasticity by means of orally administered drugs, intramuscular chemodenervation agents (alcohol, phenol, botulinum toxin A), intrathecally administered drugs (baclofen), and surgery (neurectomy, rhizotomy) has become more frequent. Family-directed use of holistic approaches for their children with cerebral palsy includes the widespread adoption of complementary and alternative therapies; however, the prevalence of their use and the cost of these options are unknown. Traditional medical techniques (physiotherapy, bracing, and orthopaedic musculoskeletal surgery) remain the mainstay of treatment strategies at this time. This seminar addresses only the musculoskeletal issues associated with cerebral palsy and only indirectly discusses the cognitive, medical, and social issues associated with this diagnosis.

Complex regional pain syndrome.

Abnormal posttraumatic pain may delay recovery and severely impact health-related quality of life. The term complex regional pain syndrome describes abnormally intense and prolonged pain that is not related to tissue damage and is sometimes a sequela of injury. Various treatment strategies, including therapy, parental interventions, and peripheral surgery, are used to manage the condition.

Factors associated with self-esteem in pre-adolescents and adolescents with cerebral palsy.

Predictors of self-esteem were examined in 50 pre-adolescents and adolescents with cerebral palsy. On average, self-esteem was high, although 30% scored below a cut-point for low self-esteem. Self-esteem was bivariately associated with female gender, better physician-assessed functional ability, greater perception of the impact of the disability, and higher perceived parent overprotectiveness. In a multivariate model, only perceived impact of the disability remained significant.

Results of palmar plating of the lunate facet combined with external fixation for the treatment of high-energy compression fractures of the distal radius.

OBJECTIVES: The study evaluated the outcome of the treatment of patients who sustained high-energy, compression-type injuries of the distal radius. DESIGN: The retrospective study evaluated the outcome of reduction and plating of the lunate facet in conjunction with standard external fixation. SETTING: A Level I trauma center. PATIENTS: Inclusion criteria for study participation included: 1) age between 18 and 65 years of age with no evidence of concomitant metabolic bone disease; and 2) a 3- or 4-part compression type fracture of the distal radius with residual displacement of the palmar lunate facet despite reduction of the dorsal cortex by the application of an external fixator. INTERVENTION: Fractures were treated with palmar plating of the depressed lunate facet combined with dorsal external fixation. MAIN OUTCOME MEASUREMENTS: Posttreatment evaluations consisted of measurements of range of motion, grip strength, radiographic evaluations, and completion of Disability of Arm, Shoulder, and Hand questionnaires. RESULTS: Three months after surgery, 20 of 21 patients exhibited full range of motion at the MCP/PIP joints. At the 2-year follow-up, an average palmar tilt of +1.0 degrees, radial inclination of 24 degrees, radial length of 12 mm, ulnar variance of 0.5 mm, intra-articular gap of 0.1 mm, and intra-articular step-off of 0.3 mm was documented. Using the Garland and Werley rating system, results were rated as excellent or good for 18 wrists, fair for 2 wrists, and poor for 1 wrist. Mean Disability of Arm, Shoulder, and Hand functional scores and athletic scores improved at 6 months. CONCLUSIONS: Reduction and plating of the lunate facet in conjunction with standard external fixation permits: 1) visualization and reduction of the palmar lunate facet; and 2) reduction of palmar tilt to neutral tilt without significant radial shortening. This technique should be considered as an acceptable option in the treatment of high-energy fractures of the distal radius.

Results of acute arthroscopically repaired triangular fibrocartilage complex injuries associated with intra-articular distal radius fractures.

PURPOSE: This study reviews the results of acute repair of peripheral ulnar-sided triangular fibrocartilage complex (TFCC) detachment associated with intra-articular distal radius fractures. TYPE OF STUDY: Two-year follow-up of patients who had undergone acute TFCC repair. METHODS: Fifty-six patients underwent arthroscopically assisted treatment of intra-articular distal radius fractures using external fixation and adjunctive percutaneous pinning between 1994 and 1998. Thirteen patients with an acute, complete tear of the ulnar attachment of the TFCC were treated using arthroscopic repair of the TFCC in addition to stabilization of the radius fracture. All patients were evaluated at a mean of 24 months (range, 17 to 35 months) with a physical examination, wrist radiographs, and a Disability of Arm, Shoulder, and Hand (DASH) module outcome assessment questionnaire. RESULTS: Average wrist flexion, extension, pronation, and supination were 67.3, 61.8, 79.1, and 86.8, respectively. The average grip strength was 78% of the uninjured side. The results of the Gartland and Werley grading system were good to excellent in 12 patients and fair in 1 patient. The DASH outcome scores revealed a mean functional score of 13 and a mean athletic score of 12. None of the patients reported ulnar-sided pain at follow-up. CONCLUSIONS: Arthroscopically assisted TFCC repair in conjunction with distal radius fixation resulted in a high degree of patient satisfaction and good to excellent clinical outcomes.

Arthroscopic reduction versus fluoroscopic reduction in the management of intra-articular distal radius fractures.

PURPOSE: Although arthroscopy offers an unparalleled view of intra-articular pathology, its use in the treatment of intra-articular distal radius fractures remains controversial. This study was designed to compare functional and radiologic outcomes of arthroscopically assisted (AA) versus fluoroscopically assisted (FA) reduction and external fixation of distal radius fractures. TYPE OF STUDY: Retrospective, case-matched comparison of 2 different procedures. METHODS: Between January 1995 and December 1999, 15 patients with comminuted intra-articular distal radius fractures underwent AA external fixation and percutaneous pinning. Fifteen patients underwent external fixation and FA reduction and pinning. Patients in both groups were matched for fracture pattern and age. RESULTS: Follow-up evaluation consisted of an evaluation of grip strength and range of motion as well as radiographic evaluation of palmar tilt, radial shortening, stepoff, and degenerative changes. Health-related quality of life outcomes were assessed using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Patients who underwent AA surgery had significantly improved supination compared with those who underwent FA surgery (88 degrees v 73 degrees; P =.02). AA reduction also resulted in improved wrist extension (mean, 77 degrees v 69 degrees; P =.01) and wrist flexion (mean, 78 degrees v 59 degrees; P =.02). Radial shortening, Knirk and Jupiter congruity grades, and DASH scores were similar for both groups. CONCLUSIONS: AA reduction and fixation of intra-articular distal radius fractures permits a more thorough inspection of the ulnar-sided components of the injury. At follow-up evaluation, patients who underwent AA procedures had a greater degree of supination, flexion, and extension than patients undergoing FA surgery. LEVEL OF EVIDENCE: Level II prospective cohort study.

Complex regional pain syndrome (reflex sympathetic dystrophy).

The management of CRPS can be approached using objective criteria in a logical and systematic fashion. Frustration during treatment is common because: (1) the pathophysiology of CRPS is incompletely understood, (2) there is significant variation in presentation due to disparate premorbid anatomy and physiology, and (3) the natural history may be affected by incomplete treatment. Therapeutic efforts that should be effective may fail, and a trial-and-error approach to treatment is often mandatory. Early recognition of CRPS and prompt intervention, however, provide the best opportunity for clinical improvement.

Periarterial sympathectomy of the foot for the treatment of necrotizing Raynaud's phenomena.

Patients with critical peripheral vascular disease and nonhealing toe ulcers secondary to collagen vascular disease often require toe amputation when nonsurgical measures fail to control their symptoms. The aim of this study was to evaluate the effectiveness of periarterial sympathectomy (PAS) of the foot/ankle in patients with unreconstructable vaso-occlusive disease and nonhealing digit ulcers unresponsive to nonsurgical measures. Five patients (seven feet and nine toe ulcers) were treated with PAS of their involved foot and followed for a minimal of 3 years (3 to 7 years). The technique included PAS of the dorsalis pedis, posterior tibial and anterior tibial arteries. Eight toe ulcers healed uneventfully within 3 months after surgery. Only one patient developed a new ulcer 5 years after PAS. The mean visual analog pain scale improved from 5.7 to 1 (P<0.03). The mean Wake Forest University (WFU) scale improved from 1.8 to 0.5 (P=0.07). There was no change in the WFU numbness score or the McCabe Cold sensitivity scale. The results suggest that foot/ankle PAS is a beneficial salvage treatment option for patients with non-reconstructable, vaso-occlusive disease that ameliorates foot symptoms, facilitates healing of toe ulcerations, and reduces the incidence of toe amputations.

Diagnosis and management of complex regional pain syndrome complicating upper extremity recovery.

Complex regional pain syndrome (CRPS) is a clinical syndrome of pain, autonomic dysfunction, trophic changes, and functional impairment. CRPS is common after hand trauma or surgery. Early diagnosis and intervention is critical for adequate recovery. The diagnosis of CRPS requires a careful history, physical examination, and supporting diagnostic testing. Optimal treatment requires a multidisciplinary approach. A large spectrum of pharmacologic interventions is efficacious in treating CRPS. Surgery may be used to relieve nociceptive foci. Patient-specific hand therapy is very important in reducing swelling, decreasing pain, and improving range of motion.

Human leukocyte antigen sensitization after structural cortical allograft implantations.

UNLABELLED: The incidence and significance of a donor-specific human leukocyte antigen antibody response to massive fresh-frozen human bone allograft implantation is not established. This study was a prospective, multicenter study of a cohort of consecutive patients who self-randomized themselves into two groups based on their alloantibody response to allograft bone transplant. The study hypothesis was that donor-directed antibodies are an independent risk factor influencing incorporation of massive frozen bone allografts. Pretransplant and posttransplant human leukocyte antigen alloantibody analysis was performed and correlated to determine pre-existing and graft-induced antibodies. The surgical outcomes of the two groups of patients were compared to determine the relationship between alloantibody response and bone graft incorporation. Preliminary results revealed that donor-specific human leukocyte antigen sensitization occurred in 17 of 32 (53%) of previously nonsensitized patients. A survival analysis of time to healing based on human leukocyte antigen status showed no evidence of an association between human leukocyte antigen status and time to healing. Longer followup in additional patients will be required to determine if this sensitization is correlated with an alteration in the time to union or with the quality or type of bone graft incorporation. LEVEL OF EVIDENCE: Therapeutic study, Level II. See the Guidelines for Authors for a complete description of levels of evidence.

Recurrence of equinus foot deformity in cerebral palsy patients following surgery: a review.

Although equinus deformity in children with cerebral palsy is often corrected with surgery, postsurgical recurrence of the deformity is not uncommon. In order to isolate factors that may be related to its recurrence, 31 studies were evaluated. Data from nine articles indicated that children younger than approximately 7 years of age at the time of surgery had a higher risk of recurrence than children who were older at the time of surgery. Recurrence rates may be understated in studies including less than a minimum of 4-5 years of patient follow-up. Lower recurrence rates are documented in diplegic patients compared with hemiplegic patients, and postoperative casting/splinting is stated, but not documented, to reduce recurrence. One study demonstrated that the use of chemodenervation delayed surgery and by inference theoretically would decrease recurrence after surgical release.

Periarterial sympathectomy in scleroderma patients: intermediate-term follow-up.

The use of periarterial sympathectomy (PAS) to manage chronic digital ischemia caused by scleroderma remains controversial. The duration of efficacy of PAS in managing scleroderma symptoms was evaluated by examining microvascular physiology, health-related quality of life, and patient satisfaction. Twenty-two patients (29 hands) with scleroderma, chronic vascular insufficiency, and a history of nonhealing digital ulcers unresponsive to nonsurgical treatment were evaluated. Isolated cold stress testing and laser Doppler fluxmetry measurements were used to evaluate microvascular perfusion before surgery and after a mean follow-up period of 31 months (range, 7-108 months). Digital temperatures did not change after surgery, but microvascular perfusion had increased significantly at a mean of 31 months in 22 hands. Health-related quality-of-life data were collected at a mean of 46 months (range, 11-108 months) after surgery. Subjective improvement (fewer ulcers, faster ulcer healing, and decreased pain) was reported for 18 of 22 patients (24 of 29 hands) at a mean follow-up period of 46 months; 6 patients remained ulcer free. Follow-up of scleroderma patients after PAS documented improved microvascular perfusion as evaluated by laser Doppler fluxmetry and by variable clinical results.

Dorsal wrist ligament insertions stabilize the scapholunate interval: cadaver study.

This study examined sequential arthroscopic sectioning of volar, interosseous, and dorsal ligaments about the scapholunate complex in cadaver wrists. We attempted to clarify the contributions of the dorsal ligamentous complex to scapholunate instability and carpal collapse. We found that after sequential sectioning of volar ligaments and the scapholunate interosseous ligament, no scapholunate diastasis or excessive scaphoid flexion occurred. After dividing the dorsal intercarpal ligament, scapholunate instability occurred without carpal collapse. With sectioning of the dorsal radiocarpal ligament from the lunate, a dorsal intercalated scapholunate instability deformity ensued. This information may be of value in comprehending the pathogenesis of scapholunate instability and carpal collapse and in devising the rationales for conservative measures and surgical intervention.

Carpal tunnel release: efficacy and recurrence rate after a limited incision release.

We retrospectively studied the postoperative outcomes of 51 patients treated for idiopathic carpal tunnel syndrome by method of a limited incision carpal tunnel release. Patients were assessed to determine: 1) palmar tenderness, 2) scar tenderness, 3) relief of symptoms, 4) complications, and 5) recurrence. Short-term follow-up included patient evaluations at 2 weeks, 4 weeks, and 10 weeks; a mean of 2.5 years of follow-up also was obtained. Postoperatively, nocturnal symptoms resolved by the 2-week visit. Palmar tenderness was noted as minimal or absent between the 4-week and 10-week visits in 47 of the 51 patients (92%). Symptom and function scores improved from 4.24 and 4.00 preoperatively to 1.18 and 1.19 postoperatively. At a mean of 2.5 years after surgery, none of the patients reported recurrent symptoms.

The pink pulseless hand.

The management of a child with a perfused, pink, but pulseless upper extremity following reduction and pinning of a type III supracondylar humerus fracture remains controversial. The authors present the initial treatment, evaluation, operative findings, and postoperative course of a 6-year-old with a pink pulseless hand. Review of the literature is included, as well as recommendations regarding operative management.