Donald G. Shurr

Electromyographic changes after carpal tunnel release

This prospective clinical study was designed to quantitate post-carpal tunnel release electromyographic (EMG) changes in the median nerve, and changes in static two-point discrimination, pinch strength, and grip strength. Carpal tunnel release was performed in 54 hands of 36 patients (average age of patients was 44.6 years). The EMG and clinical studies were completed just before surgery, at 2 weeks, and then at postoperative periods of 3, 6, 9, 12, 18, and 24 months. The sensory latencies and motor latencies were significantly (p less than 0.05) improved at the 3- and 6-month postoperative periods, respectively. The motor and sensory conduction velocities were significantly (p less than 0.05) improved as early as 2 weeks postoperatively. Two-point discrimination values were significantly (p less than 0.05) improved at 2 weeks postoperatively. For the pinch and grip strengths, significant (p less than 0.05) improvement did not occur until the 6- and 9-month postoperative periods, respectively. These results should be of considerable value, especially in the evaluation of the post-carpal tunnel release patient with persistent or recurrent symptoms.

Proximal interphalangeal joint arthroplasty.

Prosthetic implant arthroplasty of the proximal interphalangeal (PIP) joint has a limited role in the reconstruction of the rheumatoid hand. Ninety-three PIP joint arthroplasties, including 56 Flatt, 30 Swanson, and seven Niebauer implants, were reviewed with postoperative follow-up periods averaging 6.2 years. The average maximum extension/flexion for the prostheses were Flatt, 28 degrees/45 degrees; Swanson, 1 degree/40 degrees; and Niebauer, 3 degrees/26 degrees. The average active ranges of motion for the prosthetic groups were Flatt, 15 degrees; Swanson, 37 degrees; and Niebauer, 19.5 degrees. Analysis of active motion at intervals of up to ten years indicated gradually decreasing active motion for each prosthesis. Comparison of preoperative motion with motion three years after operation indicated a decrease in the Flatt prosthesis group, from 35 degrees to 20 degrees. Radiographically, cortical perforation by the prosthesis was common with the Flatt prosthesis (80%), and recurrent swan-neck deformity was frequent with the Swanson spacer (27%). Despite suboptimal clinical results, patient satisfaction was high, and the ability of patients to perform activities of daily living was acceptable.

Schultz metacarpophalangeal arthroplasty: A long-term follow-up study

We describe a prospective, long-term evaluation of the Schultz metacarpophalangeal joint implant. The prosthesis is a semiconstrained, cemented implant with a ball-in-socket articulation. Thirty-six implants were followed for an average of 10.9 years. There was a progressive decrease in range of motion and strength and a recurrence of ulnar deviation. The neck of the proximal phalangeal component fractured in 39% of the joints. Periarticular heterotopic bone formed in all joints, but was extensive in only 22%. Although some lucency of the bone-cement interface was seen in 80% of the joints, no prosthetic loosening occurred in this series. Our results indicate that long-term, intramedullary cement fixation of relatively long-stemmed components can be satisfactory. However, the articulated portion of this implant does not consistently withstand the stresses transmitted across the joint and does not provide long-term joint stability.

Mechanical Gait Analysis of Transfemoral Amputees: SACH Foot Versus the Flex-Foot

The purpose of this study was to identify gait mechanics that might explain the physiological benefits found when transfemoral amputees walked over ground using a Flex-Foot® compared to a SACH foot fastened below a hydraulic knee joint. Five active traumatic unilateral transfemoral amputees were videotaped as they walked overground at five controlled speeds ranging from 1.5 to 3.5 mph on a continuous path. Analysis of the videotape data was conducted on the mean step length, early and late swing and stance phases, and double- and single-support phases for each speed. Since there were no speedby- foot-type statistical interactions, the foot-type comparisons could be made across all speeds. The only significant differences due to foot type were found in the uninvolved double- and uninvolved single-support phases and the late stance-phase ratio (involved late stance phase/uninvolved late stance phase). These differences appear to be caused by a delay in the involved toe-off while using the Flex-Foot. The Flex-Foot is designed to deform during weight acceptance and reform giving a “pushoff” during late stance. The additional time needed to reform the Flex-Foot could explain the phase differences, and this pushoff mechanism could explain the physiological benefits of walking with the Flex-Foot compared to the SACH foot. With a pushoff, the inertia of the involved limb may be overcome, and the prosthetic limb may be recovered with less upper-body movement and thus less energy would be expended, resulting in a more efficient, symmetrical gait.

Transfemoral Amputee Physiological Requirements: Comparisons Between SACH Foot Walking and Flex-Foot Walking

This study compared exercise intensity, oxygen uptake and gait efficiency when active traumatic transfemoral amputees used a SACH foot or a Flex-Foot® attached below a hydraulic knee joint. The five male subjects completed two test sessions, one with each foot, one week apart. They walked overground at five controlled speeds ranging from 1.5 mph to 3.5 mph (40.2 m/sec to 93.9 m/sec). For each condition, when subjects had reached physiological steady state, heart rate was recorded by telemetry, and expired gas was collected in a Douglas bag and analyzed in the laboratory. There was no statistical interaction between foot type and speed allowing foot-type comparisons to be made across speed. Results of the measures analysis of variance (ANOVA) were recorded. The analyses indicate Flex-Foot walking was associated with significantly lower exercise intensity, less energy expenditure and improved gait efficiency compared to the SACH foot. The results of this study indicate the Flex-Foot is physiologically beneficial for active traumatic transfemoral amputees walking overground across a functional range of walking speeds. While the differences are relatively small, they may be clinically important given the high energy cost of transfemoral amputee walking.

The absent fifth metacarpal

Although many patterns of metacarpal abnormalities have been described, the congenital anomaly of complete or partial absence of the fifth metacarpal has not been well defined. This article reports on seven patients with longitudinal partial or complete absence of the fifth metacarpal with the ulna and the three phalanges of the little finger present.

Metacarpophalangeal joint arthroplasty with a metallic hinged prosthesis.

A long-term clinical study of 41 Flatt metallic hinged prostheses inserted in the metacarpopha-langeal joints of ten rheumatoid patients was completed to provide a historic and clinical perspective of the ongoing clinical performance of this prosthesis. Postsurgical analysis performed an average of 138 months after operation demonstrated an average active range of metacarpophalangeal joint motion of 24°, with average maximum active extension of 16° and flexion of 40°. Motion through this device in the metacarpophalangeal joint was relatively well preserved with time and was within a functional range. Recurrent digital ulnar deviation was observed in 58% of patients, digital malrotation in 50%, and extensor tendon redislocation in 45%. The prosthesis failed by screw or prong failure (47%). Periprosthetic radiolucency was common (87%), indicating poor host bone tolerance. With net bone resorption the prosthesis migrated, often perforating the cortex of the metacarpal (44%) or proximal phalanx (59%). Patient satisfaction, despite suboptimal clinical results, was high. All patients considered the appearance of the operated hand and pain relief improved. These advantages must be considered relative to the disadvantages of recurrent digital deformity, poor host tolerance, and unpredictability of clinical results.

Functional status in ulnar deficiency.

Function is the most important consideration in the evaluation of patients with congenital ulnar deficiency. The upper extremity function of 8 patients with ulnar deficiency was evaluated. None of these patients had been treated with surgical procedures directed to the elbow, forearm, or wrist. The functional criteria included: (a) active ranges of elbow, forearm, and wrist motion, (b) power grip, (c) prehension, (d) dexterity, and (e) a patients activities questionnaire. The averaged total active range of joint motion was 229 or 46% of predicted normal active motion. Power grip averaged 27% of the contralateral extremity, and prehension tests were generally well performed. Timed tests were completed an average of 11.6 s slower than the contralateral control hand. Our patients did not report any deficiencies in bimanual activities. Patients performed most poorly when their congenital anomaly included radiohumeral synostosis or congenital absence, deformity, or contracture of the ipsilateral digits. The radiographic appearances or classification of the ulnar deficiency, in the absence of radiohumeral synostosis. did not correlate well with patient function.

Physiological responses to multiple speed treadmill walking for Syme vs. transtibial amputation—a case report

Purpose: To date, there have been no longitudinal studies comparing walking at different levels of amputation. The objective of this study was to compare the self-selected walking velocity (SSWV) and selected physiologic variables during walking between a Syme and a later transtibial level of amputation for a single subject. Additional comparison was made between the SACH foot prosthesis and a dynamic response foot prosthesis. Method: A 35-year-old male with a traumatic Syme amputation later underwent elective transtibial amputation. SSWV and multiple speed treadmill walking tests (53.64, 67.05, 80.46, 93.87 and 107.28 m/min) were evaluated under three conditions (Syme prosthesis with SACH foot, transtibial prosthesis with SACH foot, and transtibial prosthesis with Flex-Foot). Results: Walking with transtibial prosthesis showed minimal differences in oxygen consumption (0 – 5% reduction), heart rate response (0 – 1% reduction), or gait efficiency (0 – 5% improvement) across all speeds when compared with Syme prosthesis (both with SACH foot). However, the SSWV was 6 – 8% faster for the transtibial SACH foot. Walking with transtibial Flex-Foot required less cardiovascular demand than with transtibial SACH foot at higher speeds. Conclusions: In this case report, it seemed that transtibial amputation did not have adverse effects on selected physiological responses at a variety of walking speeds when compared to Syme amputation, and that the use of a dynamic response foot enhanced his gait performance. Further experimental studies involving more subjects with traumatic Syme and transtibial amputations are required to better understand the effect of these two levels of amputation on energy cost of walking.

The Concept of an Entry-Level Interdisciplinary Graduate Degree Preparing Orthotists for the New Millennium Part 1: History of Orthotic and Prosthetic Education

The study of orthotics and prosthetics began with the ancient art of splint, brace, and artificial limb making. Stimulated by the World Wars and polio epidemics of the late 1940s and early 1950s, the most significant contributions to orthotics and prosthetics were made in the 20th century. In 1945, an extensive research effort begun by the National Academy of Sciences spurred research, development, and education initiatives that focused on prosthetics. In 1952, the University of California at Los Angeles provided the first formal coordinated education effort in orthotics and prosthetics as a 6 week course offered to provide practicing prosthetists with the results of a nationwide research effort. It was not until 1960 that a formal research directive was initiated in orthotics. As research developed, a curriculum was expanded to a series of courses in each discipline (orthotics or prosthetics), and the number of institutions offering the training similarly increased. Students who successfully completed these courses were awarded a certificate of completion and this model still exists today as the postBachelor’s certificate program. In 1965, New York University established the first baccalaureate degree program consisting of two years of prerequisite courses followed by two years of professional courses in orthotics and prosthetics. Subsequently, other programs developed in the 1970s and 1980s. The close relationship between the national research program and education programs ended in 1975 with the dissolution of the National Research Council, and, subsequently, orthotics and prosthetics education programs began to drift apart in their curriculum; their lowest denominator being the minimum subjects and hours established by the Education Accreditation Commission. Recognition of orthotics and prosthetics as an allied health profession in 1992 lead to the accreditation of all practitioner education programs. Advancements in orthotics and prosthetics education have slowly responded to the challenges of developing measurable outcomes, seeking funding based on limited resources, and recruiting qualified faculty in the midst of a national shortage of certified practitioners and academicians. The rapidly expanding elderly population in need of orthotics and prosthetics care, encroachment by other health care providers delivering orthotics and prosthetics services, the advancement of medicine and technology, and changes in managed health care all highlight the need for responsive, contemporary, advanced orthotics and prosthetics education programs.