European consensus on the concepts and measurement of the pathophysiological neuromuscular responses to passive muscle stretch.

BACKGROUND AND PURPOSE: To support clinical decision-making in central neurological disorders, a physical examination is used to assess responses to passive muscle stretch. However, what exactly is being assessed is expressed and interpreted in different ways. A clear diagnostic framework is lacking. Therefore, the aim was to arrive at unambiguous terminology about the concepts and measurement around pathophysiological neuromuscular response to passive muscle stretch. METHODS: During two consensus meetings, 37 experts from 12 European countries filled online questionnaires based on a Delphi approach, followed by plenary discussion after rounds. Consensus was reached for agreement ≥75%. RESULTS: The term hyper-resistance should be used to describe the phenomenon of impaired neuromuscular response during passive stretch, instead of for example 'spasticity' or 'hypertonia'. From there, it is essential to distinguish non-neural (tissue-related) from neural (central nervous system related) contributions to hyper-resistance. Tissue contributions are elasticity, viscosity and muscle shortening. Neural contributions are velocity dependent stretch hyperreflexia and non-velocity dependent involuntary background activation. The term 'spasticity' should only be used next to stretch hyperreflexia, and 'stiffness' next to passive tissue contributions. When joint angle, moment and electromyography are recorded, components of hyper-resistance within the framework can be quantitatively assessed. CONCLUSIONS: A conceptual framework of pathophysiological responses to passive muscle stretch is defined. This framework can be used in clinical assessment of hyper-resistance and will improve communication between clinicians. Components within the framework are defined by objective parameters from instrumented assessment. These parameters need experimental validation in order to develop treatment algorithms based on the aetiology of the clinical phenomena.

Plate fixation versus percutaneous rush pinning for osteosynthesis of the fibula in pilon fractures. A retrospective comparative study.

BACKGROUND: Pilon fractures are complex injuries of the ankle associated with many postoperative complications. The optimal treatment for pilon fractures has not yet been established. This study aimed to determine the efficacy and compare the results of percutaneous rush pinning of the associated fibular fracture to the conventional open reduction and internal fixation. METHODS: We included in the study all patients admitted in our department with the diagnosis of pilon fracture and associated fracture of the distal fibula and treated with primary open reduction and internal fixation between 2012 and 2018. We excluded patients treated with a two-stage approach, and those with an open fracture or neurovascular insufficiency. RESULTS: The study included 87 patients; 45 had their distal fibular fracture operatively fixed with a one-third tubular plate (ORIF group), and the remaining 42 patients underwent percutaneous intramedullary pinning of the fibula fracture with a rush nail (Rush group). There were no statistically significant differences between the groups regarding age, gender, mechanism of injury, operating, and hospitalization time. The superficial infection rate was lower in the Rush group (p =0.039), but there were no statistically significant differences in the deep tissue infection, nonunion, and malunion incidence between the groups. CONCLUSION: Percutaneous intramedullary rush pinning of the concomitant fibular fracture is a safe and reliable alternative treatment option in managing pilon fractures that could reduce the incidence of postoperative wound complications HIPPOKRATIA 2021, 25 (2):63-68.

Apophysitis of the Ischial Tuberosity: A Case Report.

INTRODUCTION: Sports-related recurrent injuries (microtrauma and trauma) of the apophyses are common in children and adolescents and could result in specific pathologies. One of them is the apophysitis or apophysiolysis of ischial tuberosity (Valtancoli or Kremser's disease) due to contraction of hamstrings, in sports with sudden accelerations and decelerations. CASE REPORT: We present the case of a male athlete who complained of pain in the left buttock and difficulty walking after a 3months old reported trauma with pain and hematoma in his left thigh, during a kick with his contralateral leg. Due to a radiographic finding of a suspicious lesion near his left ischial tuberosity, an extensive investigation that included computed tomography, magnetic resonance imaging, bone scintigraphic scan, and blood analysis followed the diagnosis of apophysitis of the ischial tuberosity was determined and the proposed non-surgical treatment had satisfactory results. CONCLUSION: The diagnosis of apophysitis of ischial tuberosity is usually delayed but has a good response to the appropriate treatment.

The Heidelberg foot measurement method: development, description and assessment.

The aim of this study was to develop and evaluate a kinematic measurement method for the foot that could be applied clinically to measure foot function including all typical foot deformities. The ankle was modelled as two anatomically based hinge joints rotating around anatomical axes estimated by the use of projection angles. For the mid- and forefoot a descriptive approach was chosen by defining angles between anatomical landmarks or reference points derived from these landmarks. The motion of 17 markers on the lower leg and foot was measured during walking gait on 10 adult participants with no known abnormalities to determine the pattern of normal foot motion, assess reliability and provide a reference against which pathological foot behaviour could be compared. Functional angles for mid- and forefoot motions were developed to improve clinical applications of the data. The combination of anatomically and technically oriented marker placement on the foot is a reliable basis for reproducible kinematic measurements and the method was shown to be viable for clinical practice.

Hip deformities in walking patients with cerebral palsy.

Hip deformities in walking patients with cerebral palsy are rare. Nineteen diplegic and four hemiplegic patients with unilateral hip subluxation were studied to determine whether or not characteristic gait patterns could be identified. All were examined clinically and radiologically as well as undergoing observational and instrumented three dimensional gait analysis. Twenty one of the patients compensated for the subluxation with an ipsilateral trunk lean and contralateral pelvic drop. These patterns were quantified in the kinematic and kinetic variables measured. We conclude that hip abductor weakness should be considered as the cause of the deformity.

Conversion of biarticular to monoarticular muscles as a component of multilevel surgery in spastic diplegia.

We treated 20 children (40 limbs) with diplegic cerebral palsy who could walk by multilevel soft tissue operative procedures including conversion of the biarticular semitendinosus and gastrocnemius to monoarticular muscles. The mean age at surgery was 11.5 years (5.6 to 17.0). All patients underwent clinical and radiological examination and three-dimensional instrumented gait analysis before and at a mean of 3.1 years (2.0 to 4.5) after surgery. The passive range of movement at the ankle, knee and hip showed improvement at follow-up. Kinematic parameters indicated a reduced pelvic range of movement and improvement of extension of the knee in single stance after operation (p < 0.0001). However, post-operative back-kneeing was detected in five of the 40 limbs. The kinetic studies showed that the power of the hamstrings and plantar flexors of the ankle was maintained while the maximum knee extensor moment during stance was reduced. The elimination of knee flexor activity of semitendinosus and gastrocnemius combined with transfer of distal rectus femoris led to an improvement in gait as confirmed by gait analysis.

Dynamic pedobarography (DPB) in operative management of cavovarus foot deformity.

Dynamic pedobarography (DPB) was performed in 21 patients, 9 male and 12 female with cavovarus foot deformity mostly of Charcot-Marie-Tooth origin. Age ranged from 14 to 52 years (mean 30 y). Twenty-six feet were examined pre- and postoperatively clinically, radiologically and by dynamic pedobarography with a follow-up time from 9 to 49 months (mean 22.5 mo). The EMED SF system was used for data collection during walking. Gait line, contact areas (CA), peak pressures (PP) and pressure time integral (PTI) were determined. According to the contact pattern the examined feet could be divided into three groups with antegrade, retrograde and inversion contact pattern. Data analysis showed postoperatively considerable increase in CA and decrease in PP and PTI. Clinical results such as plantar callosities and "roll over avoidance gait" did not always correlate with pedobarographic data. DPB adds a dynamic component in the diagnosis and management of cavovarus feet but certain limitations exist.

[Knee-bending and -stretching-spastic in infant cerebral palsy. Surgery aimed at functional improvement and its results]. / Die Kniebeuge- und die Kniestreckspastik bei der infantilen Zerebralpalse. Funktionsverbessernde Eingriffe und deren Ergebnisse.

Any treatment of disorders of the knee in patients with cerebral palsy is a complex task in terms of indications and surgical technique. Surgical management has the potential to considerably improve function in walkers as well as tetraparetic patients. The close functional relationship between the knee joint and the adjacent hip and ankle joints requires an integrated view. An increased anterior pelvic tilt aggravates any shortening of the hamstring muscles. An equinus foot deformity increases knee extensor movement. When evaluating postoperative results, it is never sufficient to indicate the postoperative range of motion only. Instead, functional evaluation criteria complemented by instrumented gait analysis must be used to define the results more quickly and to uncover postoperative problems.