Percutaneous needle tenotomies: indications, procedures, efficacy and safety. A systematic review.

BACKGROUND: Percutaneous needle tenotomies constitute a promising approach that enables direct access to tendons through minimally invasive interventions. They can be performed rapidly without need for large incisions or general anaesthesia. However, the reported procedures are heterogeneous and currently conducted without guidelines. OBJECTIVES: We aimed to determine the indications for percutaneous needle tenotomies described in the current literature. Our secondary aim was to identify the different procedures reported, as well as their efficacy and their safety. METHODS: A systematic review following PRISMA guidelines was conducted to identify original articles that mentioned percutaneous needle tenotomy in humans and reported its application, description, effectiveness or adverse events. Non-percutaneous tendinous surgical procedures and ineligible designs were excluded. The Downs and Black checklist was used to assess the risk of bias. RESULTS: A total of 540 studies were identified from the MEDLINE, Embase, Cochrane Library, and PEDro databases. Fourteen clinical studies met the inclusion criteria and were found to have an acceptable quality (674 individuals, 1664 tenotomies). Our results indicated a wide variety of indications for percutaneous needle tenotomies in children and in adults. We highlighted 24 tendons as eligible targets in the upper and lower limbs. Tenotomies were performed with either 16- or 18-Ga needles, lasted from 1 to 30 min, and were performed using various procedures. Their efficacy was mainly assessed through clinical outcomes highlighting tendon discontinuity on palpation after the procedure. Passive range-of-motion gains after tenotomy were reported for both upper and lower limbs with an estimated 5 % complication rate. CONCLUSION: This is the first review to systematically synthesize all the available evidence on the indications, procedures, efficacy and safety of percutaneous tenotomies exclusively performed with needles. Current evidence suggests that procedures are safe and effective for treating various deformities. PROSPERO REGISTRATION: CRD42022350571.

Arthroscopic shoulder suspensioplasty in painful hemiplegic shoulder subluxation-a case series.

Background: Inferior glenohumeral subluxation (GHS) can cause disabling pain in hemiplegics. Conservative treatments have not been proven to be effective or maintained over time. A few studies have shown the benefits of surgical treatment. The objective of our study was to evaluate the medium-term clinical and radiological results of arthroscopic glenohumeral suspensioplasty surgery by biceps tenodesis in the setting of painful GHS in hemiplegics. Methods: We conducted a retrospective study of patients who underwent arthroscopic glenohumeral suspensioplasty. The assessment, at a minimum of 1 year, included a clinical evaluation (pectoralis major spasticity, pain, range of motion, satisfaction) and a radiographic evaluation (Dursun classification, height of subacromial space). Results: Five patients with a mean age of 51 years (36-72 years) were included at a mean follow-up of 40 months (12-70). Satisfaction was good in 80% of patients. Pain decreased in all patients, but not significantly. Four patients (80%) would repeat the procedure if it were necessary. In all patients, a reduction in GHS over time was observed, with a reduction in subacromial height, except in 1 patient who suffered a tenodesis rupture during a fall. Conclusion: Our results suggest that arthroscopic glenohumeral suspensioplasty by biceps tenodesis may be a therapeutic option in hemiplegic patients with painful GHS.

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.

French clinical guidelines for peripheral motor nerve blocks in a PRM setting.

INTRODUCTION: Motor nerve blocks with anesthetic drug for local anesthesia are commonly used in physical and rehabilitation medicine (PRM), especially in the field of spasticity. Guidelines in this context are currently lacking. METHOD: Eighteen experts selected on the basis of their recognized experience by the scientific committees of the French PRM (SOFMER) and Anesthesia and Intensive care (SFAR) societies were invited to work and propose guidelines for the use of loco-regional anesthetic drug for motor nerve blocks in PRM setting. Eight issues were addressed: which neural blocks for which indications; drugs and contraindications; medical survey and attitude in case of adverse event; injection and guidance material; patient preparation and pain relief; efficacy assessment; patient information; education of PRM physiatrists. The Medline, Cochrane and Embase databases for the period 1999 to 2018 were consulted and 355 papers analyzed. The drafts were commented then approved by the whole group using electronic vote, before final approval by scientific committee of each society. RESULTS: No scientific evidence emerged from the literature. Thus, these guidelines are mainly based on the opinion of the expert panel. Guidelines for each issue are reported with the main points of arguments. The main question deals with the recommendation about doses for each drug: for lidocaine - up to 2mg/kg - "check contraindications, emergency truck available, no need of previous anesthetic consultation nor presence of anesthetic physician"; for ropivacaine - up to 1.5mg/kg, with a maximum of 100mg - the same but after intravenous line. Beyond these doses, SFAR guidelines have to be applied with the need of anesthetic physician. CONCLUSION: These are the first organizational guidelines devoted to increase the security of motor nerve block use in PRM settings.

Upper Limb Isokinetic Strengthening Versus Passive Mobilization in Patients With Chronic Stroke: A Randomized Controlled Trial.

OBJECTIVE: To assess the benefit of isokinetic strengthening of the upper limb (UL) in patients with chronic stroke as compared to passive mobilization. DESIGN: Randomized blinded assessor controlled trial. SETTING: Physical Medicine and Rehabilitation departments of 2 university hospitals. PARTICIPANTS: Patients (N=20) with incomplete hemiplegia (16 men; mean age, 64y; median time since stroke, 32mo). INTERVENTIONS: A 6-week comprehensive rehabilitation program, 3d/wk, 3 sessions/d. In addition, a 45-minute session per day was performed using an isokinetic dynamometer, with either isokinetic strengthening of elbow and wrist flexors/extensors (isokinetic strengthening group) or passive joint mobilization (control group). MAIN OUTCOME MEASURES: The primary endpoint was the increase in Upper Limb Fugl-Meyer Assessment (UL-FMA) score at day 45 (t1). Secondary endpoints were increases in UL-FMA scores, Box and Block Test scores, muscle strength, spasticity, and Barthel Index at t1, t2 (3mo), and t3 (6mo). RESULTS: Recruitment was stopped early because of excessive fatigue in the isokinetic strengthening group. The increase in UL-FMA score at t1 was 3.5±4.4 in the isokinetic strengthening group versus 6.0±4.5 in the control group (P=.2). Gains in distal UL-FMA scores were larger (3.1±2.8) in the control group versus 0.6±2.5 in the isokinetic strengthening group (P=.05). No significant group difference was observed in secondary endpoints. Mixed models confirmed those results. Regarding the whole sample, gains from baseline were significant for the UL-FMA at t1 (+4.8; P<.001), t2, and t3 and for the Box and Block Test at t1 (+3; P=.013) and t2. CONCLUSIONS: In a comprehensive rehabilitation program, isokinetic strengthening did not show superiority to passive mobilization for UL rehabilitation. Findings also suggest a sustained benefit in impairments and function of late UL rehabilitation programs for patients with stroke.

Percutaneous Needle Tenotomy for the Treatment of Muscle and Tendon Contractures in Adults With Brain Damage: Results and Complications.

OBJECTIVE: To study the results and complications of percutaneous needle tenotomy for superficial retracted tendons in patients with brain damage. DESIGN: Prospective observational study. SETTING: University hospital. PARTICIPANTS: Patients with severe brain damage (N=38; mean age, 60.7y; age range, 24-93y; 21 women) requiring surgical management of contractures and eligible for percutaneous needle tenotomy were enrolled between February 2015 and February 2016. INTERVENTIONS: The percutaneous needle tenotomy gesture was performed by a physical medicine and rehabilitation physician trained by an orthopedic surgeon, under local or locoregional anesthesia. Treated tendons varied among patients. MAIN OUTCOME MEASURES: All patients were evaluated at 1, 3, and 6 months to assess surgical outcomes (joint range of motion [ROM], pain, and functional improvement) while screening for complications. RESULTS: Improvements in ROM (37/38) and contractures-related pain (12/12) were satisfactory. Functional results were satisfactory (Goal Attainment Scale score ≥0) for most patients (37/38): nursing (n=12), putting shoes on (n=8), getting in bed or sitting on a chair (n=6), verticalization (n=7), transfers and gait (n=8), and grip (n=2). Five patients had complications related to the surgical gesture: cast-related complications (n=2), hand hematoma (n=2), and cutaneous necrosis of the Achilles tendon in a patient with previous obliterative arteriopathy of the lower limbs (n=1). CONCLUSIONS: Percutaneous needle tenotomy yields good results in the management of selected superficial muscle and tendon contractures. The complications rate is very low, and this treatment can be an alternative to conventional surgery in frail patients with neurologic diseases.

Somatosensory-related limitations for bimanual coordination after stroke.

BACKGROUND: Bimanual coordinated movements may be impaired after stroke, so an assessment of causes is necessary to optimize rehabilitation strategies. OBJECTIVE: We assessed the role of afference-based sources of coordination, including phase entrainment and error correction based on visual and somatosensory feedback. METHODS: In all, 10 persons with unilateral chronic stroke and 8 age-matched controls participated in a kinesthetic tracking protocol, in which the hemiparetic upper limb was passively driven by the machine. The task consisted of matching the trajectory of the driven limb as accurately as possible with the freely moving limb in 2 conditions: eyes closed and eyes open. We analyzed the continuous relative phase (CRP), the mean absolute difference between positions (ADP) between the positions of the 2 limbs, and the jerk of the matching limb. RESULTS: Coordination instability (CRP standard deviation) and mean ADP were significantly higher for patients with eyes closed, compared with patients with eyes open, controls with eyes closed, and controls with eyes open. Moreover, the jerk was higher for the nonparetic limb of patients than for the control group. Thus, the nonparetic limb did not produce optimally smooth movements even as the motor-driven paretic limb did. CONCLUSION: Besides deficits caused by interhemispheric competition and motor execution of the paretic limb, somatosensory feedback is a limiting factor in bimanual coordination after stroke. The findings have clinical implications pertaining to the design and individualization of efficient bimanual movement therapy.