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The Journal of Bone and Joint Surgery (American). 2007;89:2316-2324. doi:10.2106/JBJS.G.00285 © 2007 The Journal of Bone and Joint Surgery, Inc. What's New in Orthopaedic Rehabilitation1 Department of Orthopaedic Surgery, The Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA 19104. E-mail address for M.A. Keenan: maryann.keenan{at}uphs.upenn.edu
Specialty Update has been developed in collaboration with the Council
of Musculoskeletal Specialty Societies (COMSS) of the American Academy of
Orthopaedic Surgeons.
Orthopaedic rehabilitation involves the care of patients with complex musculoskeletal problems, which are global in nature rather than being limited to one or two anatomic locations. It is a specialty that combines biomechanics and biology in a unique manner with an approach that focuses on improving the functional outcome for individuals with musculoskeletal disability through operative and nonoperative management. This specialty encompasses patients of all ages, a broad range of anatomic locations, and a variety of musculoskeletal dysfunctions. Orthopaedic rehabilitation comprises all of the traditional orthopaedic subspecialties, including amputation surgery, prosthetic and orthotic management, neuromuscular diseases, and the variety of other neurologic disorders, with focus on the musculoskeletal system as a whole as well as on the linkages and couplings between bones, joints, muscles, and the nervous system. This Specialty Update highlights presentations and advances in several areas of orthopaedic rehabilitation that were discussed at meetings of the Orthopaedic Rehabilitation Association, the American Academy of Orthopaedic Surgeons, and other specialty organizations over the past year. Some abstracts of level-I studies in this area of expertise are also succinctly summarized. The review also highlights the papers that received the Jacqueline Perry Award and the Vernon Nickel Award, the two prestigious awards in orthopaedic rehabilitation that are presented annually by the Orthopaedic Rehabilitation Association.
Motion analysis is an important tool that is used to understand the complexities of movement and lower extremity function. Such a detailed description of function has been valuable for determining both nonoperative and operative management guidelines for individuals with abnormal gait patterns1-4. Gait-evaluation protocols involving the use of instrumented treadmills are likely to be used in the near future. Riley et al. performed a kinematic and kinetic comparison of overground and treadmill walking in a study of healthy subjects and demonstrated that treadmill gait is qualitatively and quantitatively similar to overground gait and that the mechanics of treadmill and overground gait are very similar5. Having demonstrated the essential equivalence of treadmill and overground gait, the authors proposed the possibility of incorporating treadmill-based protocols into clinical movement analysis. Bennett et al. performed an analysis of center-of-mass movement and energy recovery to outline differences between children with cerebral palsy and age-matched controls without cerebral palsy6. Children with cerebral palsy had a 33% smaller energy recovery factor than the controls did (p < 0.001). They also had 60% greater center-of-mass vertical excursion (p < 0.02) and a poorer phasic relationship between potential and kinetic energies (p < 0.02), both of which contributed to greater mechanical work performed (p < 0.003). The authors concluded that, compared with the age-matched controls without cerebral palsy, the children with cerebral palsy were mechanically less efficient in terms of their gait. Interventions that promote heel contact and rollover and greater knee stability to better utilize the kinetic energy of push-off could improve walking efficiency. Michlitsch et al. studied the relative prevalence of posterior and anterior tibialis dysfunction with use of gait analysis in a large group of patients with cerebral palsy and varus foot deformity7. The muscular contributors to varus foot deformity in seventy-eight patients (eighty-eight feet) who had cerebral palsy were evaluated with computerized motion analysis and dynamic electromyography. Data also were examined to identify any relationships between the timing of varus during gait and the contributing muscle. The study demonstrated a higher prevalence of anterior tibialis dysfunction, both alone and in combination with posterior tibialis dysfunction, as a contributor to pes varus in patients with cerebral palsy than had been reported previously. Dynamic electromyography proved to be extremely helpful for conducting the analysis. Lam et al. studied the biomechanical and electromyographic effects of conventional ankle-foot orthoses and dynamic ankle-foot orthoses on gait in patients with spastic cerebral palsy8. Thirteen patients with dynamic equinus underwent motion analysis with electromyography. Both conventional ankle-foot orthoses and dynamic ankle-foot orthoses provided longer stride length, permitted prepositioning for initial contact, and successfully controlled the excessive plantar flexion during the swing phase. The median frequency of the electromyographic signal indicated that extremely high firing was found in the lower limbs of patients as compared with controls; this high firing resulted in tiredness. The dynamic ankle-foot orthoses allowed a significantly larger total ankle range of motion than did the conventional ankle-foot orthoses. However, conventional ankle-foot orthoses significantly reduced the median frequency of the electromyographic signal, whereas dynamic ankle-foot orthoses did not. The reduced frequency seen in association with the conventional ankle-foot orthoses suggested an improvement of walking endurance. The dynamic ankle-foot orthosis had the advantage of producing less restriction of ankle movement, thereby avoiding muscular atrophy and improving orthotic compliance. Dynamic polyelectromyography has a proven role in the clinical assessment of gait and the subsequent planning for the surgical treatment of both upper and lower extremity neuromuscular disorders. Its use is not limited to research questions alone. Keenan and Mehta used dynamic polyelectromyography to help guide their surgical decision-making in the treatment of shoulder dysfunction in patients with both neurogenic and mechanical shoulder problems9. In addition to dynamic electromyographic studies, gait laboratories may be used to examine ground-reaction forces, joint motion, and foot pressures to further enhance movement analysis. The different patterns of lower limb dysfunction in patients with upper motor neuron syndromes have an impact on the priorities of gait and upper limb functional use. A number of muscles cross major joints of the lower extremity, and identification of the actual muscles that contribute to an upper motor neuron syndrome deformity is an important key to determining the clinical treatment of the resulting dysfunction10.
Bone-bridging (arthrodesis of the distal parts of the tibia and fibula) at the time of transtibial amputation is a controversial operative technique that has been anecdotally reported to improve the weight-bearing capacity of the residual limb and to decrease discomfort in the residual limb. Pinzur et al. evaluated thirty-two consecutive patients with multiple diagnoses who had had a transtibial amputation with a distal tibialfibular bone-bridge; all procedures had been performed by a single surgeon11. At an average of 16.3 months after surgery, all patients completed the Prosthetics Evaluation Questionnaire, a validated outcomes instrument specifically created to evaluate quality of life and functional demands of patients with lower extremity amputations. The responses were compared with those of seventeen preselected, highly functional transtibial amputees from two academic medical centers who previously had had a transtibial amputation with use of a traditional operative technique that did not involve bone-bridging. The average time since the amputation for those seventeen patients was 14.7 years. The "nonselected" consecutive patients with bone-bridging in the residual limb scored more favorably in the Ambulation (p = 0.037) and Frustration (p < 0.001) domains of the Prosthetics Evaluation Questionnaire and less favorably in the Appearance (p = 0.025) subscale. Their scores were similar in the other six domains. The results of that study suggest that bone-bridging at the time of transtibial amputation may enhance patient-perceived functional outcomes. Selles at al. performed a randomized controlled trial in which the functional outcome and cost efficiency of a total surface-bearing socket were compared with those of a conventional patellar tendon-bearing socket in a group of transtibial amputees12. Twenty-six adult unilateral transtibial amputees who had been walking with a prosthesis for at least one year were randomly assigned to treatment with either a total surface-bearing socket or a conventional patellar tendon-bearing socket. Outcome measures included the Prosthetics Evaluation Questionnaire score, the ability to perform mobility-related activities of daily life, and gait characteristics at baseline and three months after initial socket fitting as well as the cost of materials, the manufacturing time, and the number of visits and interventions. No significant differences were found between the groups in terms of changes in socket function (as reflected by Prosthetics Evaluation Questionnaire scores, the ability to perform mobility-related activities, and gait characteristics). With the total surface-bearing sockets, the cost of materials was significantly larger but the manufacturing time was significantly shorter and the number of visits was significantly less than with the patellar tendon-bearing sockets. Both sockets performed equally well in terms of patient satisfaction, mobility-related activities performed during daily life, and gait performance. The material costs were higher in the total surface-bearing socket group, whereas the manufacturing time was shorter in that group. Tisi and Callam evaluated the evidence comparing different surgical techniques for transtibial amputation with use of healing of the residual limb, wound infection, the reamputation rate, and mobility with a prosthetic limb as outcome measures13. Randomized controlled trials comparing two or more types of skin incisions for transtibial amputations were identified. All patients with lower limb ischemia (acute or chronic) and/or diabetic foot infection were considered for inclusion. Patients undergoing transtibial amputation for the treatment of other conditions were excluded. Analyses revealed that transtibial amputations involving the use of skew flaps or sagittal flaps conferred no advantage over the well-established long posterior flap technique. For patients with wet gangrene, a two-stage procedure with an open amputation at the ankle followed by a definitive long posterior flap amputation led to better primary healing of the residual limb than did a one-stage procedure. The choice of amputation technique had no effect on outcome and could be a simple matter of surgeon preference. Factors that might influence this choice include previous experience with a particular technique, the extent of nonviable tissue, and the location of the preexisting surgical scars. Zmitrewicz et al. conducted a study in a gait laboratory to assess the influence of energy storage and return prosthetic feet (ESAR) and multi-axis ankles on ground-reaction forces and loading symmetry between lower limbs in transtibial amputees14. The authors concluded that the gait of amputees may improve with the prescription of multi-axis ankles, which allow for greater propulsive impulses by the residual leg and improve the loading symmetry between the legs. Subjects wore two different prosthetic feet with and without a multi-axis ankle and were analyzed with use of a blind repeated-measures multivariate analysis-of-variance design. The anteroposterior ground-reaction force impulse, peak ground-reaction forces, and braking and propulsion impulse duration were analyzed as subjects walked at a self-selected speed while wearing each of the four foot-ankle prosthesis combinations. Analysis revealed that amputees generated a significantly greater propulsive impulse with the residual leg when wearing a multi-axis ankle with either the ESAR or the non-ESAR foot, which improved the propulsive symmetry between the residual and intact legs. The type of prosthetic foot had no effect on these measures. There were no significant differences in the peak residual-leg braking or propulsive ground reaction forces or the impulse durations due to the prosthetic foot, ankle, or foot-ankle interactions, although an increase in the propulsive impulse duration approached significance (p = 0.062) with a multi-axis ankle. These findings suggest that the gait of an amputee may improve with the prescription of a multi-axis ankle that allows for greater propulsive impulses by the residual leg, which improve the loading symmetry between the legs14.
Heterotopic ossification is the abnormal formation of bone within extraskeletal soft tissues. Classically, many diseases sharing this common feature were lumped under the category of myositis ossificans. The term myositis ossificans has fallen into disfavor because primary muscle inflammation is not a necessary precursor, and ossification does not always occur in muscle tissue. It frequently shows a predilection for fascia, tendons, and other mesenchymal soft tissues. Thus, the term heterotopic ossification largely has replaced myositis ossificans in the literature. A strong relationship exists between heterotopic ossification and spinal cord injury, with bone formation occurring primarily at the hips. It occurs more commonly in patients with complete injuries at a cephalad level. Similarly, periarticular heterotopic ossification is seen in patients with traumatic brain injury. Many other causes of neurologic compromise, including tetanus, poliomyelitis, Guillain-Barré syndrome, and prolonged pharmacologic paralysis during mechanical ventilation, also have been associated with heterotopic ossification. The prevalence of clinically important heterotopic ossification is between 10% and 20% in patients with central nervous system injuries. It is also associated with severe trauma, hip arthroplasty, and burns15-20. Andermahr et al. evaluated a total of 182 fractures in a study in which twenty-nine patients who had polytrauma without neurologic injury were compared with forty-eight patient who had polytrauma with traumatic brain injury21. The investigators examined the clinical parameters of excessive bone healing (hypertrophic callus formation and/or heterotopic ossification) and delayed healing. A subset of twenty-eight patients underwent serological testing for bone turnover parameters, including carboxy-terminal extension peptide of type 1 procollagen (P1CP), pyridinoline cross-linked carboxy-terminal telopeptide (1CTP), insulin-like growth factor-1 (IGF-1), insulin-like growth factor binding protein-3 (IGFBP-3), and basic fibroblast growth factor (bFGF). There was a higher rate of delayed union in the group of patients who had polytrauma without neurologic injury (45% compared with 23%) and a higher rate of excessive bone healing in the group of patients who had polytrauma with traumatic brain injury (33% compared with 17%). These differences, however, were not significant. More delayed unions were observed at the site of diaphyseal fractures in the group of patients who had polytrauma without neurologic injury (28%) than in the group of patients who had polytrauma with traumatic brain injury (15%); the difference was not significant. The prevalence of excessive bone healing after pelvic fracture was 52% in the group of patients who had polytrauma with traumatic brain injury and 21% in the group of patients who had polytrauma without neurologic injury; this difference was not significant. This finding was similar to that reported by Garland and Miller22. The P1CP level did not differ between the groups, but the collagen breakdown parameter 1CTP was significantly higher in the group of patients who had polytrauma without neurologic injury (p = 0.01 to 0.04). IGF-1 levels were below normal in both groups and did not differ between the groups. The level of IGFBP-3, an IGF-1-inhibiting and collagenase-3-activating protein, was significantly higher in the group of patients who had polytrauma without neurologic injury (p = 0.017 to 0.037). The level of bFGF did not vary between the groups. Increased serum levels of 1CTP and IGFBP-3 in the group of patients who had polytrauma without neurologic injury suggested that excessive bone healing in patients with a traumatic bone injury is secondary to decreased collagen breakdown rather than increased synthesis. Heterotopic ossification at the knee rarely causes complete ankylosis, and therefore surgical excision may not be performed. However, heterotopic ossification does decrease the motion of the knee and commonly causes a flexion deformity, which impairs function. Fuller et al. reviewed seventeen consecutive patients (twenty-two knees) with neurologic injuries who had excision of heterotopic ossification from around the knee23. The diagnoses included traumatic brain injury (fifteen patients), anoxia (one patient), and spinal cord injury (one patient). The average age of the patients was thirty-three years (range, nineteen to fifty-one years), and the average duration of follow-up was thirty-two months. The arc of knee motion improved by 65° postoperatively. Mean extension improved from 16° preoperatively to 2° post-operatively. Mean flexion improved from 57° preoperatively to 107° postoperatively. Walking ability and sitting function improved as a result of treatment. The authors concluded that surgical excision of heterotopic ossification of the knee is an effective procedure for increasing joint mobility and function. Ippolito et al. evaluated the results of excision of areas of heterotopic ossification in a study of five patients (seven knees) who had sustained a traumatic brain injury24. Before the procedure, all of the knees were fixed in a flexed position that ranged from 10° to 40° and had a painful arc of motion that ranged from 20° to 70° of flexion. None of the patients could walk, and some of them could barely sit in a wheelchair. At the end of the operation, the arc of motion was markedly improved in all knees (from 0° to 130° in three knees, from 0° to 120° in three knees, and from 10° to 120° in one knee). In an attempt to prevent postoperative loss of motion and recurrence of the ossification, continuous passive motion was applied to the involved knee (or knees) for six weeks before a full rehabilitation program was started. After an average duration of follow-up of thirty-four months, all patients could walk and all knees were pain-free. All knees had more than a functional arc of motion, and there was no recurrence of heterotopic ossification in any of the knees. Patients with good neuromuscular control had the best general functional results. The routine use of a continuous-passive-motion machine was associated with no recurrence of ossification, and there was some late loss of motion after its use was discontinued.
A notable proportion of patients with cervical spinal cord injury suffer from respiratory muscle paralysis and depend on chronic mechanical ventilation. In selected patients, diaphragm pacing through electrical stimulation of the phrenic nerves provides an alternative to mechanical ventilation, with notable advantages in life quality25. Several available diaphragm pacing systems are available, including conventional systems in which electrodes are positioned directly on the phrenic nerves through a thoracotomy and less invasive systems in which electrodes are placed within the diaphragm with use of laparoscopy. For patients with only unilateral phrenic nerve function, a combined intercostal and unilateral diaphragm pacing system is under development. For patients with ventilator-dependent tetraplegia, there are alternative methods of ventilatory support that offer substantial benefits compared with mechanical ventilation. Leypold et al. studied the characteristics of spinal cord injury lesions with use of magnetic resonance imaging in patients who had been managed with or without methylprednisolone26. Patients with cervical spinal injury who were managed with the recommended dose of methylprednisolone (a bolus of 30 mg/kg plus 5.4 mg/kg per hour over twenty-four hours), initiated within eight hours after the injury, were compared with historical controls who did not receive steroids. Methylprednisolone treatment had no significant effect on the duration of spinal cord edema when the treated patients were compared with the untreated subjects. The imaging features did suggest that methylprednisolone therapy in the acute phase of spinal cord injury may decrease the extent of intramedullary spinal cord hemorrhage. Tsutsumi et al. evaluated the recovery of motor function and the occurrence of early complications in patients who had received a high dose of methylprednisolone sodium succinate within eight hours after an acute cervical spinal cord injury27. Seventy patients were studied, including thirty-seven patients in the methylprednisolone sodium succinate group who were managed within eight hours after the injury according to the Second National Acute Spinal Cord Injury Study protocol and thirty-three patients who were not managed with methylprednisolone sodium succinate. Improvements in the American Spinal Injury Association (ASIA) motor score were compared between two groups. Among patients with complete motor loss at the time of admission and follow-up periods, improvements of myotomal levels were compared between the methylprednisolone sodium succinate group (fifteen patients) and the non-methylprednisolone sodium succinate group (twenty-one patients). Early complications within six weeks were compared between the methylprednisolone sodium succinate group and the non-methylprednisolone sodium succinate group. Among the patients who had incomplete paralysis at the time of admission, those in the methylprednisolone sodium succinate group improved more significantly in terms of the ASIA motor score than did those in the non-methylprednisolone sodium succinate group at six weeks and six months after the injury. Meanwhile, among the patients who had complete paralysis at the time of admission, those in the methylprednisolone sodium succinate group did not show significantly more change in the motor score than did those in the non-methylprednisolone sodium succinate group. Improvement in myotomal levels was not significantly different between the two groups. Early complications occurred in ten patients in the methylprednisolone sodium succinate group, compared with fourteen patients in the non-methylprednisolone sodium succinate group. The authors concluded that methylprednisolone sodium succinate should be administered to patients with incomplete cervical spinal cord injury according to the Second National Acute Spinal Cord Injury Study protocol. Murray et al. reported on the patient's perspective of the impact of spinal cord injury on physical, cognitive, and emotional function and on quality of life28. Sixty-three patients with spinal cord injury (including thirty-two with recent injuries and thirty-one with established injuries) were evaluated with the Ruff Neurobehavioral Inventory to determine their subjective evaluation of preinjury and postinjury functioning. Current happiness levels were also evaluated with use of the Subjective Happiness Scale. A follow-up assessment was performed six months later to examine changes over time. A significant difference was found between the perception of preinjury and postinjury function on composite cognitive, physical, and quality-of-life scales and on several of the emotional subscales, including those related to anxiety, paranoia, suspicion, and substance abuse. Pain following a spinal cord injury was noted to be a signficant predictor of cognitive and emotional well-being and quality of life. With the exception of a decrease in happiness, there were no significant changes in any measures over the six-month time-period. The authors concluded that there are significant changes in some aspects of emotional functioning and in patients' perceptions of physical and cognitive functioning as well as of quality of life before and after spinal cord injury. In a prospective, double-blind, randomized, placebocontrolled study, Gilchrist et al. evaluated the role of oral alendronate administration in preserving bone mineral density when administered soon after an acute spinal cord injury29. Thirty-one patients with an acute spinal cord injury were randomly allocated to receive oral alendronate (70 mg/week) or placebo, within ten days after the injury, for twelve months. The main outcome measurements that were evaluated at the time of entry into the study and at three, six, twelve, and eighteen months after the injury included total body bone density, lumbar and hip bone mineral density, ultrasonographic findings in the calcaneus, and twenty-four-hour urinary calcium and serum C-telopeptide (Beta-CTX) levels. At the time of entry, the patients in the two groups were well matched in terms of age, gender, the severity of neurologic deficit, bone mineral density, the urinary calcium level, and the Beta-CTX level. Bone mineral density indices declined steadily in the placebo group, and this effect was attenuated significantly by alendronate. After twelve months, there was a 5.3% difference (p < 0.001) in total body bone mineral density and a 17.6% difference (p < 0.001) in the total hip bone mineral density between the two groups. Compared with placebo, alendronate induced significant (p < 0.001) reductions in urinary calcium excretion and serum Beta-CTX levels. No treatment-related side effects were noted. The authors concluded that alendronate therapy at a dose of 70 mg per week, initiated soon after acute spinal cord injury, prevents bone loss and is not associated with side effects. In the Spinal Cord Injury Locomotor Trial, twelve weeks of step training with body-weight support on a treadmill that included overground practice was compared with a defined but more conventional overground mobility intervention in patients with an incomplete traumatic spinal cord injury; in both groups, the intervention was initiated within eight weeks after the time of the injury30. This single-blinded, randomized trial included 107 ASIA grade-C and D patients and thirty-eight ASIA grade-B patients with lesions between C5 and L3 who were unable to walk at the time of admission for rehabilitation. The Functional Independence Measure (FIM-L) for walking, 15-m walking speed, and the lower extremity motor score (LEMS) were collected every two weeks. The authors reported no significant differences at the time of entry or during the treatment phase. Few ASIA grade-B patients and most ASIA grade-C and D patients achieved functional walking ability by the end of twelve weeks, consistent with the primary outcome data at six months. Walking-related measures assessed at two-week intervals revealed that time after spinal cord injury is an important variable for entering patients into a trial with mobility outcomes. By about six weeks after entry, most patients who will recover have improvement of the FIM-L to >3 and have improvement in walking speed.
Lower extremity disease, including peripheral arterial disease, peripheral neuropathy, foot ulceration, or lower extremity amputation, is twice as common in diabetic individuals as it is in nondiabetic individuals, and it affects 30% of diabetic individuals who are more than forty years old. Foot ulcers cause substantial emotional, physical, productivity, and financial losses. Among individuals who are diagnosed with diabetes mellitus, the prevalence of foot ulcers is 4% to 10%, the annual population-based incidence is 1.0% to 4.1%, and the lifetime incidence may be as high as 25%. These ulcers frequently become infected, cause great morbidity, and engender considerable financial cost. Nonhealing ulcers lead to amputation 85% of the time. The key risk factors of diabetic foot ulceration include neuropathy, deformity, and repetitive stress (trauma)31. The key factors associated with nonhealing of diabetic foot wounds (and therefore amputation) include wound depth, the presence of infection, and the presence of ischemia31. Singh et al. conducted a study to systematically review the evidence on the efficacy of methods that have been advocated for preventing foot ulcers in the primary care setting32. Screening all patients who have diabetes is important in order to identify those who are at risk for foot ulceration. Prevention of diabetic foot ulcers can begin in the primary care setting with a brief history and Semmes-Weinstein monofilament testing. The neuropathy then can be quantified with other tools such as biothesiometry and confirmed with the measurement of plantar foot pressures and an assessment of the lower extremity vascular status with Doppler ultrasound and ankle-brachial blood pressure indices. With these measurements and other findings from the history and physical examination, clinicians can determine the risk and the appropriate type of intervention. Patients at high risk for foot ulcers can benefit from prophylactic intervention, including patient education, prescription footwear, intensive podiatric care, and evaluation for surgical intervention32. Another effective adjunctive tool to prevent foot complications in individuals at high risk for lower extremity ulceration and amputation is at-home patient self-monitoring of daily foot temperatures. Lavery et al. conducted a randomized study of two groups of patients who had diabetes mellitus33. One group was managed with standard therapy consisting of therapeutic footwear, diabetic foot education, and a regular foot evaluation by a podiatrist. The other group was managed with enhanced therapy involving the use of a handheld infrared skin thermometer for self-evaluation. When foot temperatures were elevated, patients were instructed to reduce their activity and to contact the study nurse. They were instructed to reduce the number of steps taken in the ensuing days until the temperature difference between corresponding sites in both feet had decreased. The clinical outcomes that were evaluated included the incidence of diabetic foot ulcers, the development of foot infections, and the rates of Charcot fractures and amputations. The authors demonstrated that the enhanced-therapy group had significantly fewer diabetic foot complications. Armstrong et al. conducted a randomized controlled trial to compare the proportion of ulcers that healed following treatment with a total contact cast (TCC) or with other available and popular devices (removable cast walkers, half-shoes, and therapeutic depth inlay shoes)34. The authors used a technique to modify the removable cast walker by wrapping it in a layer of cohesive or plaster bandage. This technique has been termed the instant TCC. The modification of a standard removable cast walker increased the proportion of ulcers that healed and the rate of healing of diabetic neuropathic wounds. In a similar study, Katz et al. compared the effectiveness of a removable cast walker that was rendered immovable (by wrapping with a single strip of fiberglass casting material) with that of a TCC for the treatment of diabetic neuropathic plantar foot ulcers35. In a randomized trial of forty-one patients with nonischemic, neuropathic plantar foot ulcers, the authors found that while the healing rates in the two groups were statistically equivalent, the immovable TCC took significantly less time to place and remove than did a standard total contact cast. Furthermore, there was a lower cost associated with the use of the immovable TCC. Boyko et al. reported that significant predictors of foot ulceration are glycosylated or glycated hemoglobin levels (hemoglobin A1c, Hb1c, HbA1c or HgA1c), impaired vision, previous foot ulceration, previous amputation, monofilament insensitivity, tinea pedis, and onychomycosis36. Glycosylated hemoglobin is a form of hemoglobin that is used primarily to identify the plasma glucose concentration over time. Its name is sometimes abbreviated to A1C. It is formed in a nonenzymatic pathway by hemoglobin's normal exposure to high plasma levels of glucose. Boyko et al. concluded that readily available clinical information has substantial predictive power for the development of diabetic foot ulcers and may help to accurately target individuals who are at high risk of this outcome for preventive interventions. All infected foot lesions require antibiotic therapy. Diabetes can cause immunological deficiencies, including abnormal neutrophil chemotaxis, phagocytosis, and intracellular killing. Granulocyte colony-stimulating factor (G-CSF) is an endogenous hematopoietic growth factor that induces terminal differentiation and release of neutrophils from the bone marrow. In the study by Cruciani et al., various G-CSF preparations were administered parenterally to a total of 167 patients for three to twenty-one days37. The authors concluded that G-CSF treatment does not appear to hasten the clinical resolution of diabetic foot infection or ulceration but is associated with a reduced rate of amputation and other surgical procedures. The use of G-CSF should be considered, especially for patients with limb-threatening infections.
Chronic wounds are very common in industrialized countries. It has been suggested that 1% of the population of Western countries will have some kind of leg ulcer at some time, and the annual cost for the treatment of all chronic wounds may be as high as $1 billion in the United Kingdom alone. With an aging population, one may expect both the prevalence and the cost of chronic wounds to continue to rise. Chronic wounds have different etiologies. Four chronic wound types can be considered: (1) diabetic foot ulcers (the most common chronic wounds in Western industrialized countries), (2) venous leg ulcers (caused by the presence of sustained high venous pressures secondary to reflux or obstruction), (3) arterial leg ulcers (caused by arterial insufficiency), and (4) pressure ulcers (caused by unrelieved pressure or friction). There are many therapeutic options for chronic wounds. Hyperbaric oxygen therapy is one option38,39. One study demonstrated that ulcer healing and the rate of minor amputation were not influenced by hyperbaric oxygen therapy, but there is evidence that hyperbaric oxygen therapy reduces the risk of major amputation in diabetic patients. Because of the modest number of patients managed with hyperbaric oxygen therapy, this result should be interpreted cautiously and the benefit from hyperbaric oxygen therapy will need to be examined in further, rigorous randomized trials. Pressure-relieving beds, mattresses, and seat cushions are widely used in both institutional and noninstitutional settings as aids for the prevention of pressure ulcers. For individuals who are at high risk for the development of pressure ulcers, consideration should be given to the use of higher-specification foam mattresses (foam alternatives) rather than standard hospital foam mattresses40. The merits of constant low-pressure mattresses and alternating-pressure mattresses for the prevention of pressure ulcers are unclear. The use of pressure-relief devices (such as polymer pads) on operating tables for high-risk patients is associated with a reduction in the postoperative development of pressure ulcers.
Each year, the Orthopaedic Rehabilitation Association holds a competition and assigns awards for the best original research paper by a resident or fellow. These awards are named in honor of the two pioneers in this field, Dr. Jacqueline Perry and Dr. Vernon Nickel. The Perry Award paper is presented at the Orthopaedic Rehabilitation Association Specialty Day Program, held in conjunction with the annual meeting of the American Academy of Orthopaedic Surgeons. The Nickel Award paper is presented at the Annual Meeting of the Orthopaedic Rehabilitation Association. Each prize also has a cash award to defer the travel expenses of the awardee.
The Jacqueline Perry Award Paper 2005: Surgical Intervention for Shoulder Deformity Resulting from Upper Motor Neuron Syndromes The shoulders were divided into two groups. Group I consisted of seventeen shoulders that had a dynamic deformity according to dynamic electromyography and motor control analysis. Group II consisted of the remaining ten shoulders, all of which had a static contracture. The patients in Group I were managed with fractional lengthening of the pectoralis major, latissimus dorsi, and teres major muscles involved in the dynamic spastic deformity. The patients in Group II were managed with releases of the pectoralis major, subscapularis, latissimus dorsi, and teres major tendons to correct the static deformity. In Group I, operative treatment was associated with a significant improvement in active motion. While there was also an increase in passive motion, this was not nearly as pronounced as the volitional activity improvement in these patients. Thirteen of the seventeen patients who had a shoulder injury in Group I also had concurrent surgical procedures at the elbow or hand to improve global function of the upper extremity. The patients in Group I were satisfied with the results of surgery and the functional improvement. In Group II, operative treatment resulted in significant improvement in resting posture and passive range of motion as compared with the preoperative status. The patients in Group II were not subjected to upper extremity motor control analysis because they did not have volitional control of the shoulder muscles. The patients in Group II and their caregivers were satisfied with the results of surgery. The improved passive mobility of the shoulder resulted in easier and better care for these patients.
The Vernon Nickel Award Paper 2005: Musculoskeletal Workload Versus Musculoskeletal Clinical Confidence Among Primary Care Physicians
The Jacqueline Perry Award Paper 2006: Cost-Effectiveness of Surgical Intervention for Cerebrospastic Equinovarus Deformity Twenty-two patients (six male and sixteen female) were available for follow-up. The average age at the time of the stroke was 48.6 years (range, three to sixty-six years). The average age at the time of surgery was 55.5 years. The average duration of nonsurgical treatment was eighty-three months. The average duration of postoperative follow-up was 17.1 months. The equinovarus deformity was corrected in all patients, and the ambulation scores improved significantly. The average monthly cost of nonoperative treatment was $820. There was a significant difference between the average cost of nonoperative treatment ($38,146/patient) and operative treatment ($12,911/patient) (p = 0.03). The postoperative satisfaction score was significantly higher than the preoperative score (6.2 compared with 3.6; p = 0.001). The authors concluded that prolonged conservative care for spastic equinovarus deformity might not be cost-effective. In their study, the cost of surgical management was equivalent to twenty-nine months of conservative care and therefore the authors proposed that operative correction is cost-effective for patients who have prospects of maintaining an active lifestyle.
The Vernon Nickel Award Paper 2006: Bioprotection of Tendon Repair. Use of Botulinum Toxin A in Achillis Tendon Repair in Rats
The Jacqueline Perry Award Paper 2007: Outcomes of Total Joint Arthroplasties in Adults with Post-Poliomyelitis Syndrome Five hundred patients were evaluated, and 108 patients underwent surgery during the study. In the group of 108 patients who underwent surgery, seventeen patients underwent a total of nineteen lower extremity joint replacements (including ten knee arthroplasties and nine hip arthroplasties). The average age at the time of surgery was 66.5 years. The average age when poliomyelitis infection occurred was fifty-eight months. The average pain score was 7 preoperatively and 0.7 postoperatively. For the ten knees that underwent total knee arthroplasty, the Knee Society score increased from a mean of 28 to 88. For the nine hips that underwent total hip arthroplasty, the mean Harris hip score increased from 63 to 94. Manual muscle testing of lower extremity muscle groups in both lower extremities revealed no loss of strength after surgery. The patients demonstrated significant improvement on a functional walking scale, from a mean of 2.9 preoperatively to a mean of 4.5 postoperatively. There were no wound-healing problems. No radiographic evidence of loosening or wear of the prosthesis was observed after a mean duration of followup of ninety-two months. All patients reported full satisfaction with the result. The authors concluded that total joint arthroplasty can be a safe and effective method for the treatment of osteoarthritis in patients with sequelae of poliomyelitis or post-poliomyelitis syndrome, with resolution of pain, improved function, and preservation of strength. Careful preoperative planning and a comprehensive postoperative rehabilitation program are essential for a successful outcome.
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Introduction
Motion Analysis and Dynamic...