Biomedical subjects
Publications and source records attributed to R L Waters.
Cerebrovascular accidents are among the most serious medical problems in the United States. In Part I of this report, the pathophysiology, types of impairment, and evaluation of the stroke patient were discussed. In this report, Part II, the management of extremity deformities will be reviewed.
The problem of inadequate hip stability prevents many patients with head trauma, stroke, or spinal injury from balancing on one limb in order to take a step. There is no adequate orthotic substitute for hip instability, and electrical stimulation with surface electrodes cannot effectively activate the deep hip muscles. This report describes a clinical program in which electrical stimulation via surgically placed electrodes is combined with routine tendon lengthening and transfers and physical therapy. The electrodes are fixed to the epimysium and the leads directed subcutaneously to exit the skin at a common site for attachment to a commercially available stimulator. Preliminary results indicate that functional muscle contractions of the deep hip muscles can be obtained with epimysial electrodes and that stimulation can be used to augment walking ability. The results demonstrate the safety and effectiveness of percutaneous electrical stimulation and contribute to the development of a practical, implanted stimulation system for patients who do not regain hip instability after an upper motor neuron lesion.
Thirty-eight (49 per cent) of seventy-seven paraplegic patients whose level of injury was at or caudad to the second thoracic vertebra were found to have signs and symptoms of carpal tunnel syndrome. The prevalence of carpal tunnel syndrome was found to increase with the length of time after the injury. In the eighteen patients in whom manometric studies were done, the carpal tunnel pressures when the wrist was in the neutral position were higher than those that have been reported in non-paraplegic patients who did not have carpal tunnel syndrome but were lower than the values in non-paraplegic patients who did have the syndrome. When the wrist was in flexion, the pressures were similar to the values that have been reported for non-paraplegic patients. However, in the paraplegic patients, regardless of whether or not they had carpal tunnel syndrome, the pressures that developed when the wrist was in extension were significantly higher than those in non-paraplegic patients, regardless of whether or not they had carpal tunnel syndrome. Most of the activities of daily living of paraplegic patients, including the maneuver to relieve ischial pressure that consists of arising from the seated position using the extended arms, are performed with the wrists locked in maximum extension. The pressure that develops in the carpal canal during this forced extension of the wrist, probably combined with the repetitive trauma to the volar aspect of the extended wrist while propelling a wheelchair, contributes to the high frequency with which carpal tunnel syndrome is found in paraplegic patients.
Sixty consecutive patients admitted to the spinal cord injury unit at a Downey, California medical center were evaluated for hand and upper extremity pain. Patients averaged nine months postinjury and had an average age of 37 years. Seven patients (11.7%) complained of diffuse hand pain, swelling, and stiffness. All patients with complaints were evaluated with three-phase radionuclide scintigraphy. Six of those seven patients had scintigrams consistent with reflex sympathetic dystrophy (RSD), an overall incidence of 10%. Three of these six patients were treated with stellate ganglion blocks, which gave relief of symptoms and allowed return to their rehabilitation program. An awareness of RSD as a cause of pain in spinal cord injured patients should lead to earlier recognition and treatment.
Paraplegic patients rely almost exclusively on their upper extremities for weight-bearing activities such as transfers and wheelchair propulsion. Eighty-four paraplegic patients whose injury level was T2 or below and who were at least one year from spinal cord injury were screened for upper extremity complaints. Fifty-seven (67.8%) had complaints of pain in one or more areas of their upper extremities. The most common complaints were shoulder pain and/or pain relating to carpal tunnel syndrome. Twenty-five (30%) complained of shoulder pain during transfer activities. Symptoms were found to increase with time from injury. As the long-term survival of spinal cord injured patients continues to improve, an increased awareness of the complications of the weight-bearing upper extremity is necessary to keep these patients functioning in society.
The energy expenditure and gait characteristics of eleven subjects who had a unilateral arthrodesis of the hip and ten subjects who had a unilateral arthrodesis of the ankle were measured during a twenty-minute walking trial. Oxygen consumption was determined and heart rate, respiratory rate, and step frequency were monitored. The average walking speed for both groups was sixty-seven meters per minute, which is 84 per cent of normal gait velocity. After an arthrodesis of the ankle, the average rate of oxygen consumption was 12.0 milliliters per kilogram of body weight per meter, which is 3 per cent more than normal. The oxygen cost averaged 0.166 milliliter per kilogram per meter, resulting in a gait efficiency of 90 per cent. After arthrodesis of the hip, the mean rate of oxygen consumption was 14.9 milliliters per kilogram of body weight per meter, which is 32 per cent greater than normal. The oxygen cost, 0.223 milliliter per kilogram per meter, represented a gait efficiency of 53 per cent. The physiological energy expenditure by the subject after an arthrodesis of the hip was found to be significantly greater than after an arthrodesis of the ankle and was more than that reported previously after a total hip arthroplasty for unilateral degenerative disease.
Cerebrovascular accidents remain one of the most serious medical problems in the United States. They are responsible for 200,000 deaths per year and are the leading cause of hemiplegia in the adult. The purpose of these reports is to review the orthopaedic aspects of stroke rehabilitation, with emphasis on functional defects, evaluation of the patient, and methods of treatment. Part I will discuss the pathophysiologic changes and patient evaluation. Part II will discuss the surgical and nonsurgical management of extremity deformities.
Flexor spasticity is common in the upper extremity after insult to the central nervous system. This leads to decreased function and hygiene problems as a result of the inability to extend the fingers. The results of fractional lengthening of the finger flexors of 27 patients with upper extremity flexor spasticity of the finger flexors were examined. Patients were divided preoperatively into those with potentially functional hands and those who were nonfunctional based on the presence of motor control and hand sensibility. Follow-up time averaged 33 months. Postoperatively, all five nonfunctional hands, which lacked any motor control, improved in posture, and the hygiene problems resolved. Twenty of the 22 patients with potentially functional hands (91%) improved their spastic hand function score, a mean of 3.7 points. Two patients (9%) decreased their spastic hand function score as a result of overlengthening of the finger flexors, with loss of grip strength.
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Fifteen patients with traumatic quadriplegia who had transfer of the brachioradialis to the flexor pollicis longus were evaluated to determine the influence of triceps function on pinch strength. Pinch was measured with the elbow free and with the elbow locked at 90 degrees in an orthosis that served as an external means of blocking elbow flexion in those patients with impaired triceps strength. Those patients having two foot-pounds or less elbow extension torque had an average pinch of 1.20 kg without elbow immobilization. With the elbow immobilized, pinch strength increased 153%, averaging 3.04 pounds. Those patients having more than two foot-pounds elbow extension torque had an average pinch of 4.08 pounds with the elbow free and pinch strength was not improved by immobilization in the orthosis. The absence of triceps function significantly decreases the effectiveness of the brachioradialis when used to motor a tendon transfer. Surgical procedures, such as posterior deltoid to triceps transfer, which provide active elbow extension can be expected to significantly increase the pinch strength supplied through the brachioradialis transfer in patients without voluntary elbow extension.
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The energy consumption associated with unilateral nonweight-bearing (three-point) crutch ambulation was evaluated in a group of 25 newly injured fracture patients immobilized in a long or short leg cast. After 5 min of crutch ambulation, the rate of oxygen uptake was 32% greater than the value for normal walking (averaging 15.7 ml/kg-min); the heart rate was 53% greater than normal (averaging 153 beats/min); and the respiratory quotient was markedly elevated (averaging 1.03). In those subjects able to ambulate for 10 min, these values averaged 17.6 ml/kg-min and 173 beats/min, approaching the peak values for maximal upper extremity exercise. The prescription of three-point crutch ambulation is a severe exercise challenge requiring strenuous arm and shoulder exertion under anaerobic conditions. These findings account for the common clinical experience that the newly injured fracture patient, unable to weight bear on an injured limb and requiring crutches, is a severely restricted ambulator.
The physiologic energy expenditure of walking was measured in patients with severe arthritis. Nine patients were tested following Girdlestone hip resection arthroplasty, six patients prior to total knee arthroplasty (TKA) for unilateral osteoarthritis of the knee, and 49 rheumatoid arthritis patients prior to unilateral TKA; 27 were retested after operation. The results were compared with previously published pre- and postoperative data for total hip arthroplasty (THA) following primary osteoarthritis. There were severe energetic penalties caused by rheumatoid or osteoarthritis involving the hip or knee or following Girdlestone arthroplasty. Walking speed was severely reduced in all groups (range, 33-46 m/minute). The rate of oxygen consumption was not significantly greater than the mean rate of oxygen uptake for normal subjects; however, the oxygen cost per meter travelled was elevated because of the slow walking speed. The heart rate was significantly elevated in all patient groups. The elevated cardiac response can be accounted for on the basis of deconditioning resulting from the patients' pain, limited ambulatory activities, and the systemic effects of rheumatoid disease. In addition, the elevated cardiac response may be caused by added physical exertion by the arms in patients on crutches or walkers. The improvements in speed and energy cost were the same for the group of rheumatoid patients tested after unilateral TKA as in the group of patients tested before and after THA. The clinician can anticipate the same magnitude of improvement from surgery in a rheumatoid patient as in an osteoarthritis patient if the primary joint disease is restricted to a single joint.
The long-term results of the key grip procedure (tenodesis of the flexor pollicis longus tendon to the radius, release of the A1 pulley, and percutaneous pin fixation of the interphalangeal joint of the thumb) were evaluated in 10 tetraplegic patients. Seven patients also had tenodesis of the extensor pollicis longus and brevis tendons to prevent flexion at the metacarpophalangeal (MP) joint. Patients were examined an average of 7.4 years after surgery. Progressive flexion of the MP joint gradually occurred, indicating failure of the extensor tenodesis. Excessive bowstringing of the flexor pollicis longus tendon across the MP joint occurred in nine patients. Because of failure of the extensor tenodesis and bowstringing of the flexor tendon, the patients had to progressively extend the wrist further to pinch small objects. Functional testing demonstrated improved hand use in eight patients. Lateral pinch strength was related to wrist extension torque.
The medical records of 179 patients were reviewed to identify complications related to the use of the halo external skeletal-fixation device. The complications that were identified included pin-loosening in 36 per cent of the patients, pin-site infection in 20 per cent, pressure sores under either a plastic vest or a plaster cast in 11 per cent, nerve injury in 2 per cent, dural penetration in 1 per cent, dysphagia in 2 per cent, cosmetically disfiguring scars in 9 per cent, and severe pin discomfort in 18 per cent. One hundred and eighty (25 per cent) of the 716 pins used had become loose at least once, and an infection had developed at sixty-seven pin sites (9 per cent). Two-thirds of the pins that were loose or associated with infection required change or removal. These complication rates, particularly of pin-loosening and infection, are exceedingly high. Attention to details in pin application, pin maintenance, and proper pin-site care may minimize the number of complications.
A follow-up of Moberg's key grip procedure was performed to evaluate the adequacy of interphalangeal joint stabilization of the thumb by means of two methods of percutaneous pin fixation. Five of 16 patients in whom a single, smooth, 2 mm Kirschner wire had been used showed significant complications as a result of distal migration. None of the seven patients who had fixation with a specially designed, 3.2 mm, threaded, slotted pin had any complications.
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Two hundred twenty-two cervical spine stabilization procedures in 212 patients are reviewed. In 114 posterior cervical fusions, 88 anterior fusions, and ten combined procedures, no deaths occurred. Surgical complication rates were similar, but more severe complications were noted with anterior cervical fusions, including tracheoesophageal problems and transient neurologic loss. Six cases of graft dislodgement requiring reoperation also occurred. In long-term follow-up evaluations, 36 anterior fusion patients developed progressive kyphotic deformity averaging 22 degrees between surgery and the time solid fusion was obtained. Degenerative changes above and below the fusion mass were detected in 36 of 59 patients treated by anterior surgery. Posterior cervical fusion patients were noted to have no significant late change in alignment, and degenerative changes were infrequent. However, 73 of 98 patients had significant extension of fusion mass beyond the originally intended levels of stabilization. Because anterior cervical spine fusion was associated with significant complications of graft dislodgement and tracheoesophageal trauma, as well as postsurgical progressive deformity, the authors recommend posterior wiring and fusion as the procedure of choice to treat cervical spine instability and permit halo-free postsurgical rehabilitation. When anterior neural decompression and fusion is necessary, concomitant posterior wiring and fusion or halo vest immobilization may be necessary to maintain reduction and prevent kyphotic angulation, because posterior ligamentous disruption is not always grossly evident on radiographic examination.