Wrist shortening arthrodesis with volar plate in a dorsal position for spastic wrist contracture.

Total wrist arthrodesis in severe wrist flexion deformities (greater than 60°) due to spasticity represents a valid therapeutic option. It aims to improve the hand's appearance, hygiene, function and to prevent the deformity from getting worse. The objective of this study is to evaluate the clinical and anatomical results of wrist shortening arthrodesis using a classic volar plate in the dorsal position in functional surgery for central spastic hands. We conducted a single-center analysis of a series of patients who underwent this shortening arthrodesis. The review at a minimum 1-year follow-up included a clinical evaluation (House score, INOM score, patient satisfaction and complications), and anatomical evaluation (arthrodesis position, bone healing and carpometacarpal arthropathy). Twenty-eight patients with a mean age of 40.6 years (18-74) were included at a mean follow-up of 30.6 months (12-75). The fusion rate was 100%. No carpometacarpal arthropathy was noted. The mean position of the fused wrist was 11° extension and 15° ulnar tilt. There were two complications (7%): one postoperative hematoma and one case of discomfort due to impingement that required plate removal. The House score was significantly improved postoperatively (2.4 (0-5) versus 1.8 (0-4), p < 0.001), as was the INOM score (45 (12-64) versus 63 (36-84), p < 0.001). The patient satisfaction rate was 93%. The use of a simple and common material (volar plate in dorsal position) during this challenging surgery (spastic wrist contracture), provides good anatomical results and high patient satisfaction. LEVEL OF EVIDENCE: Level 4, case series, therapeutic study.

What can be expected from tendon transfers in the upper limb in central nervous system disorders?

In addition to motor deficits, central nervous system disorders combine major alterations in the motor pattern with spasticity and over time, contractures. Their varied clinical presentation makes their assessment and the therapeutic strategy more complex. For these reasons, tendon transfers in this population will have more limited indications and above all, will have to be integrated into a complex surgical program combining other procedures such as tendon lengthening, selective neurotomies and joint stabilization. The surgical strategy is far from being obvious. When faced with clinical presentations having very different objectives-functional or comfort only-it is difficult at first sight to build a standardized surgical program. We therefore propose a method to evaluate these patients, thanks to a score (INOM) that integrates prognostic factors and parameters to be corrected surgically. Three components guide this program: a prognostic factor (proximal motor control of the shoulder and elbow), correction of abnormal limb postures and restoration of active elbow, wrist and finger extension. The surgical strategy can be constructed from the INOM score which establishes the priorities for care. Nerve blocks and botulinum toxin injections are essential tools for this analysis. They help distinguish between spasticity and contracture, and can unmask certain antagonistic muscles. A tendon transfer in this population will be just as effective by the function it restores as by the action it suppresses in a malpositioned limb. For each joint, we describe the indications for tendon transfers and their relative role among the techniques with which they must be combined.

Results and complications of superficialis-to-profundus tendon transfer in brain-damaged patients, a series of 26 patients.

INTRODUCTION: In hemiplegic patients with a spastic clenched fist deformity, one of the goals of surgery is to address the hygiene, nursing and appearance problems. Transfer of the flexor digitorum superficialis (FDS) to the flexor digitorum profundus (FDP), initially described by Braun and colleagues, opens the non-functional hand in these patients. The primary objective of our study was to confirm the effectiveness of this technique for correcting these deformities. The secondary objectives were to demonstrate potential functional gains and to identify potential complications. MATERIAL AND METHODS: A Braun procedure was performed in 26 patients (9 women, 17 men, ranging in age from 36 to 79 years). The overall appearance of the hand was graded using the Keenan classification system. Complications related to the surgery were documented. The hand's function was evaluated with the House score. RESULTS: The average follow-up was 47 months. Preoperatively, all patients had a class V hand: severe clenched-fist deformity with zero pulp-to-palm distance. Postoperatively, 10 patients had a type I hand (open hand, with less than 20° spontaneous extension deficit of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints) and 12 patients had a type II hand (20° to 40° spontaneous extension deficit of the MCP and PIP joints). The mean House score for all patients went from 0 to 0.88, and seven patients had functional improvements. Four patients had a forearm supination posture, 10 had intrinsic deformity with spontaneous MCP flexion and 6 had a swan-neck deformity. CONCLUSION: Superficialis-to-profundus tendon transfer (STP) provides satisfactory outcomes in terms of hand opening, with some patients also experiencing improved hand function. However, the complications cannot be ignored. LEVEL OF EVIDENCE: IV-retrospective or historical series.

Innovative technologies applied to sensorimotor rehabilitation after stroke.

Innovative technologies for sensorimotor rehabilitation after stroke have dramatically increased these past 20 years. Based on a review of the literature on "Medline" and "Web of Science" between 1990 and 2013, we offer an overview of available tools and their current level of validation. Neuromuscular electric stimulation and/or functional electric stimulation are widely used and highly suspected of being effective in upper or lower limb stroke rehabilitation. Robotic rehabilitation has yielded various results in the literature. It seems to have some effect on functional capacities when used for the upper limb. Its effectiveness in gait training is more controversial. Virtual reality is widely used in the rehabilitation of cognitive and motor impairments, as well as posture, with admitted benefits. Non-invasive brain stimulation (rTMS and TDCS) are promising in this indication but clinical evidence of their effectiveness is still lacking. In the same manner, these past five years, neurofeedback techniques based on brain signal recordings have emerged with a special focus on their therapeutic relevance in rehabilitation. Technological devices applied to rehabilitation are revolutionizing our clinical practices. Most of them are based on advances in neurosciences allowing us to better understand the phenomenon of brain plasticity, which underlies the effectiveness of rehabilitation. The acceptation and "real use" of those devices is still an issue since most of them are not easily available in current practice.

Isokinetic muscle strengthening after acquired cerebral damage: a literature review.

OBJECTIVE: Isokinetic strengthening is a rehabilitation technique rarely used in stroke patients. However, the potential benefits of force and endurance training in this population are strongly suspected. METHOD: This literature review synthesizes the results of clinical trials on this topic. The research was conducted on PubMed, using "Stroke", "rehabilitation", "isokinetic", "upper limb" and "training" as keywords. RESULTS: Seventeen studies focusing on the use of isokinetics in assessment or rehabilitation (six studies) following stroke were reviewed. For the lower limb, muscle strength and walking ability improved after isokinetic rehabilitation programs. For the upper limb, the only two studies found in the literature suggest improvement in the strength of the trained muscles, of grip force, of the Fugl-Meyer motor score and of global functional capacities. This review does not reveal any consensus on the protocols to be implemented: type of muscle contraction, velocities…. CONCLUSION: While isokinetic strengthening has not proven its efficiency in rehabilitation of the upper limb following stroke, its interest with regard to rehabilitation of the lower limbs has been recognized. Randomized controlled trials in this field are necessary to confirm its efficiency, especially concerning upper arm rehabilitation.