Mary Ann E. Keenan

Resection of heterotopic ossification in the adult with head trauma.

Lesions of heterotopic ossification were excised from thirty-seven joints in twenty-three adults who had had injuries to the brain. The lesions were excised from twenty-three elbows, twelve hips, and two shoulders. Patients were retrospectively divided into five categories according to the neural residua (cognitive and physical deficits). The patients in Class I (minimum cognitive and physical disability) and patients in Class II (minimum cognitive disability and moderate physical disability) who had fair or good selective control of the affected extremity had the best prognosis for maintaining the range of motion resulting from resecting the lesion and improving function postoperatively. They also had a low incidence of recurrence of the lesion. Seven of the nine elbows and eight of the eight hips in patients in these classes had successful results. All three of the patients in Class V (severe cognitive and physical deficits) who had a lesion of the hip and all eight of the patients in Class V with poor selective control had a poor result. In the twenty-five joints for which adequate follow-up radiographs were available to determine if the lesion recurred, fourteen recurrences were identified (56 per cent). Eleven of these patients were considered to have a poor result. Nine of the fourteen recurrences occurred in patients in Class V. Radiographic evidence of the maturity of the lesion and a normal level of alkaline phosphatase were of limited importance in predicting a low rate of recurrence. The over-all complications included four superficial infections and no instances of osteomyelitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors affecting balance and ambulation following stroke.

Ninety consecutive patients with hemiplegic involvement following a single cerebrovascular accident were studied to assess the relative importance of factors affecting balance and ambulation. Only 50% of the patients achieved a community level of ambulation. Intact balance reactions correlated strongly with the ability to walk (r = 0.79). Balance was found to be dependent on limb control and proprioception. Age, sex, hemiplegic side, and structural factors did not correlate with function or recovery. The total score in each category of function was more highly correlated with balance and ambulation than were the individual scores.

Heterotopic ossification following traumatic brain injury and spinal cord injury.

&NA; Heterotopic ossification associated with neurologic injury, or neurogenic heterotopic ossification, tends to form at major synovial joints surrounded by spastic muscles. It is commonly associated with traumatic brain or spinal cord injury and with other causes of upper motor neuron lesions. Heterotopic ossification can result in a variety of complications, including nerve impingement, joint ankylosis, complex regional pain syndrome, osteoporosis, and softtissue infection. The associated decline in range of motion may greatly limit activities of daily living, such as positioning and transferring and maintenance of hygiene, thereby adversely affecting quality of life. Management of heterotopic ossification is aimed at limiting its progression and maximizing function of the affected joint. Nonsurgical treatment is appropriate for early heterotopic ossification; however, surgical excision should be considered in cases of joint ankylosis or significantly decreased range of motion before complications arise. Patient selection, timing of excision, and postoperative prophylaxis are important components of proper management.

The Impact of Instrumented Gait Analysis on Surgical Planning: Treatment of Spastic Equinovarus Deformity of the Foot and Ankle

Background: Despite the logic behind instrumented gait analysis, its specific contribution to clinical and surgical decision making is not well known. Our purpose in this study was to determine the influence of gait analysis with dynamic electromyography upon surgical planning in patients with upper motor neuron syndrome and gait dysfunction. Methods: Two surgeons prospectively evaluated 36 consecutive adult patients with a spastic equinovarus deformity of the foot and ankle. After an initial history and physical exam, each surgeon independently formulated a surgical plan. Surgical treatment options for each individual muscle/tendon unit crossing the ankle included lengthening, transfer, release or no surgery. After the initial clinical evaluation and surgical planning, all patients then underwent instrumented gait analysis collecting kinetic, kinematic and poly-EMG data using a standard protocol by a single experienced physiatrist. Each surgeon reviewed the gait studies and patients independently and again formulated a surgical plan. The surgical plans were compared for each surgeon before and after gait study. The agreement between the two surgeons surgical plans was also compared before and after gait study. Each patient was evaluated for the clinical outcome of surgery. Results: Overall a change was made in 64% of the surgical plans after the gait study. The frequency of changing the surgical plan was not significantly different between the more and less experienced surgeons. The agreement between surgeons increased from 0.34 to 0.76 (p = 0.009) after the gait study. The number of surgical procedures planned by each surgeon converged after the gait studies. Correction of the varus deformity was seen in all patients that underwent surgical treatment. Conclusion: Instrumented gait analysis alters surgical planning for patients with equinovarus deformity of the foot and ankle and can produce higher agreement between surgeons in surgical planning. Clinical Relevance: The equinovarus deformity is due to a variety of deforming forces and a single, best operation does not exist to correct all equinovarus deformities. Rather, a muscle specific approach that identifies the deforming forces will produce the best outcomes when treating the spastic equinovarus deformity.

Reflex sympathetic dystrophy in brain-injured patients

&NA; One‐hundred consecutive patients were prospectively evaluated on admission to our Brain Injury Unit for signs and symptoms of reflex sympathetic dystrophy (RSD) in the upper extremity. Patients averaged 4 months postinjury and had an average age of 29 years. Thirteen patients had clinical signs and symptoms of RSD and were then evaluated with standard radiographs and 3‐phase radionuclide scintigraphy. Twelve of 13 patients had 3‐phase bone scans (TPBS) consistent with RSD (12% overall incidence). RSD was present exclusively in the spastic upper extremity. There were 9 patients with hemiparesis and 3 with quadraparesis. There was a significantly higher (P < 0.01) incidence of associated upper extremity injury in the group with RSD (75%). All patients had a mean Rancho Cognitive Level of V and initial Glasgow Coma Scores less than 8. Patients who developed RSD had lower Glasgow Coma Scores than the non‐RSD patients. Brain‐injured patients often display agitation, hyperalgesia, disuse or neglect of the RSD‐involved extremity. In addition, these patients are often cognitively unable to vocalize complaints of pain. Undiagnosed RSD in these patients can result in a significant delay in rehabilitation and possible loss of the use of an otherwise functional upper extremity.

Percutaneous phenol block of the musculocutaneous nerve to control elbow flexor spasticity

Twenty-three extremities in 17 brain-injured adults were prospectively studied to evaluate the effectiveness of percutaneous phenol blocks of the musculocutaneous nerve in controlling spasticity of the biceps and brachialis muscles. Twenty-one (93%) of the extremities improved after the initial injection. The mean resting position decreased from 120 degrees of flexion to 69 degrees. Elbow range of motion increased an average of 53 degrees. There were no complications. Two patients did not respond to the initial injection and required repeat nerve blocks. Concomitant phenol motor point block of the brachioradialis muscle further improved elbow motion. The mean duration of the block was 5 months. Follow-up averaged 21 months. This study indicates that percutaneous phenol injection of the musculocutaneous nerve provides reliable, temporary relief of spasticity in patients with potential for further neurologic improvement.

Correction of severe spastic flexion contractures in the nonfunctional hand

The superficialis to profundus transfer has been a time-honored treatment of spasticity in nonfunctional hands, but it does not address the many associated problems. Fourteen patients were treated with 15 procedures (1 bilateral) designed to relieve severe flexion contractures of the hand and wrist over a 3-year period with a single-stage comprehensive surgical correction consisting of superficialis to profundus transfer, wrist flexor release, flexor pollicis longus lengthening, wrist arthrodesis, carpal tunnel release, and ulnar motor branch neurectomy or intrinsic release. For all, nonoperative treatment had failed or there were chronic skin problems. The follow-up period averaged 1 year. In 13 of 15 patients, there was wrist fusion after the index procedure, with 1 patient requiring replating and another uniting after prolonged casting. Two patients had a residual claw hand with only partial correction of a thumb-in-palm deformity. All preoperative hygiene problems and infections resolved. The comprehensive protocol allowed correction of severe contractures of the hand and wrist by a single operation with improved care and appearance of the hand.

Dynamic electromyography to assess elbow spasticity

Control of elbow motion was evaluated in 45 extremities of adults with spasticity resulting from traumatic brain injury with use of dynamic electromyography. Simultaneous recording of elbow motion was obtained using a double parallelogram goniometer. Thirty-four male and 9 female patients were studied. Mean elbow flexion was 85 degrees and mean extension was 20 degrees. The average time of elbow flexion was 1.8 seconds. Extension time was prolonged to a mean of 4.0 seconds. Dynamic electromyography revealed a consistent pattern of muscle activity. Severe spasticity was noted in the brachioradialis muscle. Moderate spasticity was present in the biceps and only mild spasticity was seen in the brachialis muscle. Normal phasic muscle activity was the rule in the triceps. All patients had active elbow flexion, but the flexor spasticity limited smooth extension. Elbow flexor spasticity, especially of the brachioradialis and biceps muscles, commonly interferes with hand placement. Lengthening of the biceps and brachialis tendons combined with release of the brachioradialis enhances elbow motion and improves hand placement.

Peripheral nerve injuries in the adult with traumatic brain injury.

Fifty adult patients who sustained a traumatic brain injury (TBI) were screened for the presence of a peripheral nerve injury (PNI). All suspected patients had diagnostic electromyography performed in order to confirm the clinical findings. The incidence of PNI with TBI was 34%. A variety of nerve injuries were seen, the most frequent of which were ulnar nerve entrapment at the elbow (10%) and brachial plexus injuries (10%). No patient initiated a complaint that led to the diagnosis. In addition, all the neuropathies were missed prior to admission. The neuropathies commonly were found in the neurologically impaired extremity and associated with spasticity. The results of this study suggest that patients sustaining a TBI have a significant and higher incidence of PNI as a complication than previously reported.

Surgical resection of heterotopic bone about the elbow: an institutional experience with traumatic and neurologic etiologies.

PURPOSE We evaluated the outcomes of patients with elbow heterotopic ossification (HO) who underwent surgical intervention. Our goal was to elucidate differences in outcome of surgical treatment between those patients with traumatic brain injury, direct elbow trauma, or combined etiologies. In addition, we used regression analysis to adjust for confounding factors (such as age, gender, preoperative range of motion [ROM], location of HO, chronicity of HO [ie, time from HO formation to surgery], and whether motor control was spastic or normal) on the relationship between surgical outcome and etiology. METHODS We reviewed 60 patients (64 elbows) surgically treated for heterotopic ossification. A total of 42 patients had trauma as the primary etiology, 15 had traumatic brain injury, and 7 had combined etiologies. All had pain or functional limitations at presentation. All patients had surgical resection of their HO. Functional and ROM outcomes were recorded. RESULTS Mean preoperative arc of motion for the entire cohort was 57° (range, 0° to 150°). Mean postoperative arc for the entire cohort was 106° (range, 0° to 145°) at a mean follow-up of 44 months (range, 21-72 mo), demonstrating a significant gain. Average gain, in arc of motion was 49° (range, 10° to 140°). Gains in motion were not significantly different in any individual etiologic group. A total of 6% of cases were complicated by infection, 13% of cases had recurrence of HO, and 11% of cases required repeat surgery for infection or recurrence. Preoperative ROM was an important independent predictor of final range achieved and gain in ROM after surgical intervention. Recurrence rates were higher in patients with neurologic involvement. Postoperative stiffness was related to preoperative stiffness, delay of surgery longer than 12 months, and anterior location of the HO. CONCLUSIONS Surgical excision of heterotopic bone about the elbow results in significant gains in ROM regardless of etiology. The likelihood of recurrence is higher in patients with central nervous system injuries than in patients with purely localized trauma.