Entire Limb Research Articles

Medial opening low tibial osteotomy shifts the load laterally not only at the ankle joint but also at the knee joint.

The purpose of this study was to determine the effects of medial opening low tibial osteotomy (LTO) on lower limb alignment, including the knee joint, 1 year after low tibial osteotomy. This study included 20 legs of 20 patients (mean age, 66.8 ± 5.4 years) who underwent LTO for medial ankle osteoarthritis and evaluated the changes in the hip-knee-ankle angle (HKA), percentage hip-to-ankle line (%HA), percentage hip-to-calcaneal line (%HC), medial proximal tibial angle (MPTA), knee joint line convergence angle (K-JLCA), tibio-calcaneal angle (TCA), tibial anterior surface angle (TAS), tibio-plafond inclination (TPI), talar inclination (TI), ankle joint line convergence angle (A-JLCA), mechanical ankle joint axis point (MAJAP) on radiographs and the Japanese Society for Surgery of the Foot (JSSF) ankle/hindfoot scale before and 1 year after low tibial osteotomy. The mean preoperative/postoperative measured values showed the following: HKA (degrees) of 1.0 ± 3.7/-0.8 ± 3.7; %HC of 38.8 ± 10.0/53.8 ± 16.1; MPTA (degrees) of 85.6 ± 2.4/87.6 ± 2.1; and A-JLCA (degrees) of 4.2 ± 2.9/1.1 ± 2.3 respectively. Including other measurements, a significant increase in the %HA, %HC, MPTA, TCA, TAS, MAJAP and JSSF ankle/hindfoot scale was observed postoperatively, whereas a significant decrease in the HKA, TPA, TI and A-JLCA was observed postoperatively (p < 0.05). With the numbers available, no significant differences were observed between the preoperative and postoperative values of K-JLCA (n.s.). After LTO, the entire lower limb alignment became valgus, and the loading points of the knee and ankle joints shifted laterally. These changes must be considered when performing LTO, especially in patients with lateral knee OA. Ⅳ.

Factitious blue edema: a case report

Blue edema or factitious edema is an edema located in a finger, a hand or an entire limb, induced by voluntary stricture by a tourniquet. It is spectacular in its appearance but benign in its evolution. We report a case initially suspected of phlegmon of the right upper limb and which finally turned out to be factitious edema. A 14, year-old girl presenting for a painful swelling of the left upper limb, going up to the arm and evolving for a week. On clinical examination, we noted an impressive edema of the left upper limb predominantly in the hand, with fingers blocked in half-flexion. Edema had a purplish color with thin and scaly skin on the dorsal side of the hand. We suspected a problem of infectious or vascular origin, and completed by biological and radiological explorations without abnormalities. The patient was admitted and improved under broad-spectrum antibiotic therapy, but the appearance of the same symptoms in the contralateral limb, with a careful examination of the integuments of the upper limb noting a mark of strangulation in the middle of the right arm, allowed the diagnosis of factitious blue edema.

Innervation of the human sternoclavicular joint.

The sternoclavicular joint (SCJ) functions as the basal joint of the entire upper limb and must move in the proper pattern for normal scapular motion. Afferent sensations from joints, such as proprioception and pain sensation, are important for maintaining the proper motion and condition of joints. Detailed anatomical data are useful for discussing injuries or surgeries that impair the afferent nerve to the SCJ. Nerve branches to SCJs were examined on 12 sides, and the subclavian nerve was investigated on six sides to clarify whether it innervates this joint. On seven of the 12 sides, the SCJ was innervated by two nerves, (1) a branch from the medial supraclavicular nerve that ran medially along the clavicle and (2) a branch from the lateral pectoral nerve that innervated the clavicular head and upper part of the sternocostal head of the pectoralis major. This branch ran medially behind the clavicular head of the pectoralis major and reached the SCJ. In the remaining five sides, the SCJ was innervated solely by the branch from the medial supraclavicular nerve. Subclavian nerves ended within the subclavius muscle or periosteum of the clavicle and were separate from the SCJs. Our data on the route of nerve branches to the SCJ suggest that injury or surgery, such as clavicle fracture or resection of the clavicular head of the pectoralis major for myocutaneous flap transfer, can impair the SCJ's afferent nerve supply.

Contemporary Management of the Upper Limb in Apert Syndrome: A Review.

Apert syndrome is a relatively rare genetic disorder with a constellation of distinct craniofacial deformities and bilateral syndactyly of the hands and feet. Although the literature contains ample evidence for the need to treat cranial, midfacial, and hand abnormalities, there are severe shortcomings in the literature when attempting to describe the pathology and management of the entire upper limb in patients with Apert syndrome. A thorough literature search was performed using PubMed, Scopus, Web of Science, and Google Scholar, on the management of the upper extremity in Apert syndrome, including the shoulder, elbow, and hand. Our findings of the literature discuss the clinical presentation and management trends of the upper extremity in patients with Apert syndrome. Through multicenter collaboration, discussion among experts in the field, and evidence gathered from the literature, we propose treatment algorithms to treat deformities of the hand, shoulder, and elbow in patients with Apert syndrome. This review identifies that even if hand pathologies have been correctly treated, shoulder and elbow abnormalities in patients with Apert syndrome are largely ignored. To optimize outcomes, added cognizance of additional upper limb congenital differences and their management should be highly advocated in this patient population.

Electromyographic Analysis of Large Muscle Activity in Progressive Collapsing Foot Deformity.

There are various deformities described in the spectrum of Progressive Collapsing Foot Deformity (PCFD) which not only have adverse effects on the foot but also on the entire lower limb. Early lower limb muscular fatigue and pain during exertion is the most common complaint of patients with PCFD. Surface electromyography (sEMG) provides an accurate assessment of muscle activity. In this study, we aim to compare the activities of quadriceps, hamstrings, and gastrosoleus muscle groups of adult patients with PCFD with normal lower limbs and correlate the radiological parameters and functional effects of PCFD with the activities. Thirty patients with bilateral PCFD and 30 controls underwent weight-bearing anteroposterior (AP), lateral, and hindfoot alignment radiographs of the foot. Radiographic parameters of PCFD were assessed. Surface electromyography was used to assess the quadriceps, hamstrings, and gastrosoleus activities, and this was compared between the 2 groups and correlated with radiological measurements of PCFD. Tegner activity questionnaire was used to assess the functional effects of collapsed arch. Electrical activities of all muscle groups were significantly higher in cases than controls. Meary's angle and hindfoot moment arm had significant correlations with hamstring activity (P = .013) and gastrosoleus activity (P = .027), respectively. Tegner scores of cases were significantly lower than those of controls (P = .041). The PCFD causes an increase in activity of large muscles of the affected lower limb which act on joints other than those in the foot. This finding may be due to several compensatory mechanisms that counteract the deforming forces. This may be a cause for the frequent complaint, early fatigue, and hence functional impairment. However, most radiological parameters did not correlate with muscle activities and larger study size may be required for further association. Diagnostic: Level 3.

Decreased moment of inertia of the lower limb facilitates a rapid hip internal rotation in a simulated foot impact maneuver. A laboratory-controlled biomechanical study for a precursor mechanism of noncontact anterior cruciate ligament injury.

Anterior cruciate ligament injury frequently occurs in the deceleration with the knee-extended position. In addition, a rapid hip internal rotation is concomitantly observed. However, how the extended knee position induces the hip internal rotation is unclear. Sixteen healthy participants performed the simulated foot impact task on the experimental chair. To vary the knee flexion angle, the following four-foot placement positions relative to the pelvis segment, i.e.: 1) near; 2) middle; 3) far; and 4) far + heel strike, were tested. The reflective marker positions and the ground reaction force (GRF) data were collected. The moment of inertia of the entire lower limb around its long axis as well as the peak hip internal rotation angular velocity were calculated and compared among four conditions (Wilcoxon Signed-Rank Test with Bonferroni correction, P<0.0083). As the knee extended from the near to far + heel strike condition, the moment of inertia of the entire lower limb significantly decreased and hip internal rotation angular velocity significantly increased (P<0.001). The extended knee position with far foot placement from torso reduces the inertial resistance of the entire lower limb around its long axis and is vulnerable to the hip internal rotation.

The Intrarater and Interrater Reliability of the OMT Classification Among Physicians With a Different Background.

The Oberg-Manske-Tonkin (OMT) classification established excellent reliability scores in several validation studies. However, one study published in 2022 found much lower scores in a subanalysis of their sample when very simple anomalies were excluded. Our study assessed the reliability of the OMT among physicians with a different background, all involved in congenital hand anomaly care, and analyzed codes with less agreement. Time required for classification was recorded to give an indication on its usability. One hundred digital cases were classified twice with a minimal 1-month time interval, with the use of the 2020 version of the OMT. Two pediatric hand surgeons, 2 rehabilitation specialists, and 2 plastic surgery residents participated in this reliability analysis. The use of multiple codes was allowed. The intra- and interrater reliability was assessed for all 15 possible rater couples by calculating percentage of agreement. Cohen's kappa was calculated along with a 95% confidence interval. For the analysis of individual codes with less agreement, we calculated positive agreement with the use of a summed agreement table. Time necessary for classification was documented in seconds. The inter- and intrarater agreement was moderate with a mean Cohen's kappa of 0.45 and 0.60 retrospectively. On average, 39 seconds per case were necessary for the first and 24 seconds for the second rating. Background did not influence the level of agreement. Lowest agreement levels (ie, lowest positive agreement) were observed with all the arthrogryposis multiplex congenita subgroups, the "other" subgroups of isolated congenital contractures, syndromic syndactyly, and synpolydactyly. Codes commonly used interchangeably were symbrachydactyly and transverse deficiency and the distinction between these anomalies of only the hand or the entire upper limb; symbrachydactyly and brachydactyly; and camptodactyly and distal arthrogryposis. Our study showed a moderate reliability, emphasizing the complexity of this heterogeneous patient population. Despite its imperfections, the OMT remains the best and most versatile classification tool at hand. Its main purpose may lie in contributing to a universal language for research. I.

Sex Differences in Clinical Presentation of Lower Extremity Deep Vein Thrombosis.

Background: Differences between men and women in the clinical features and extent of lower limb deep vein thrombosis (DVT) may influence DVT diagnostic algorithms involving pretest clinical probability (PTP) assessment, D-dimer, and compression ultrasonography (CUS). Aims: To assess differences in DVT clinical presentation between men and women and their effect on PTP and D-dimer. Methods: We conducted a retrospective study in outpatients referred for suspected DVT of the lower limbs to our vascular emergency department from January 2005 to December 2019. Patients underwent PTP assessment with the Wells score, D-dimer testing, and CUS. Results: More women were referred for suspected DVT than men (M/F: 1,785/2,821; F: 61.4%; p < 0.0001). Women were older than men (median age: 71 vs. 67 years; p = 0.0001), DVT was diagnosed in 436 patients (9.4%) but in more men than women (M: 210 [11.8%] vs. F: 226 [8%]; p = 0.0002), with more proximal DVT in men than women (M: 131 7.3% vs. F: 124 [4.4%]; p = 0.00021). PTP was more likely in men (355 [19.9%]) than women (455 [16.2%]) (p = 0.0011); more men had swelling in the entire limb, increased calf circumference by >3 cm compared with the contralateral limb, and pitting edema, than women. D-dimer levels (available in 65% of patients) were more frequently positive in women with DVT than in men (94.6% vs. 85.7%; p = 0.016). However, a positive D-dimer and/or likely PTP was similarly frequent in men (92%) and women (96%) with DVT. Conclusions: More women than men are referred for suspected DVT, and men have a higher prevalence of proximal DVT. However, current algorithms for DVT diagnosis perform similarly in men and in women.

Progression of fluid infiltration on non-contrast magnetic resonance imaging in breast cancer-related lymphedema: A comparative analysis with indocyanine green lymphography

BackgroundNon-contrast magnetic resonance imaging (NMRI) has been reported as valuable for the assessment of lymphedema. However, the correlation between NMRI findings and indocyanine green lymphography (ICG-L) findings remains elusive. MethodsThis single-center retrospective study included 26 patients diagnosed with breast cancer-related lymphedema. We examined the prevalence of fluid infiltration in eight regions of the upper extremity, the type of fluid distribution, and the dominant segment of edema on NMRI in comparison to the ICG-L stage. Statistical analysis was performed using the Cochran–Armitage trend test, Spearman’s rank correlation test, and Fisher’s exact test. ResultsThe regional fluid infiltration significantly increased with the progression of the ICG-L stage (hand, forearm, elbow, and upper arm: p = 0.003, <0.001, <0.001, and <0.001, respectively). The fluid distribution significantly advanced with the progression of the ICG-L stage as follows (rs = 0.80; p < 0.001): no edema in ICG-L stage 0, edema in either the hand or elbow in ICG-L stage I, edemas in both the elbow and hand in ICG-L stage II, three segmental edemas centered on the forearm or elbow in ICG-L stage III, and edema encompassing the entire upper limb in ICG-L stage IV-V. Additionally, the dominant segment of edema tended to shift from the hand to the elbow and further to the forearm as the ICG-L stage progressed (p < 0.001). ConclusionsFluid infiltration observed on NMRI exhibited distinct patterns with the progression of the ICG-L stage. We believe that anatomical information regarding fluid distribution would potentially contribute to optimizing surgical efficacy.

CORRELAÇÃO ENTRE TESTES FUNCIONAIS E AVALIAÇÃO ISOCINÉTICA DO JOELHO EM ATLETAS CORREDORES DE RUA

ABSTRACT Introduction: The assessment of biomechanical changes related to the lower limbs is necessary in clinical practice to measure the potential risks of injury and the influences on existing dysfunction. Biomechanical changes related to previous ankle injuries are known to influence the performance of the entire lower limb. Objective: The aim of this study was to correlate muscle strength tests, performance tests and ankle stability with the Single Hop Test (SHT). Methods: 82 amateur runners were evaluated with isokinetic tests of quadriceps and hamstring muscle strength, as well as Y Balance Test (YBT), Weight-bearing Lung Test (WBLT), and the SHT. Results: The results showed there was a significant correlation between the SHT and the YBT in subjects with hamstring/quadriceps ratio (I/Q ratio) &lt;0.55, and the length of the unilateral SHT with the peak torque of ipsilateral knee extensors. Conclusion: The study was successful in correlating the functional tests in question with the results obtained in isokinetic dynamometry. Level of Evidence V; Cross-Sectional Study.

Foot Care Prioritization Among Health Care Providers Treating Diabetic Patients in Saudi Arabia: A Survey-Based Study.

Diabetic foot disease (DFD) is a significant complication associated with diabetes, characterized by the potential for progressive amputation of specific foot segments or the entire lower limb in the absence of timely identification of infection and intervention. The aim of our research is to evaluate the degree of importance given to foot care by healthcare professionals who are responsible for treating individuals with diabetes in Riyadh, Saudi Arabia. This cross-sectional study utilized an online survey previously validated in Australia. The mean foot care prioritization score was used to identify the dummy variable for binary logistic regression analysis, which was used to identify predictors of foot care prioritization. A total of 222 participants were involved in this study. Assessing for the risk of developing foot complications, visually inspecting feet for wounds, and providing or recommending footwear to prevent foot complications were the most commonly reported practices, accounting for 80.60% (n = 178), 76.10% (n = 169), and 75.20% (n = 167), respectively. The most commonly referred patients to a specialist tertiary multi-disciplinary foot care team were patients with ulcers in patients with absent foot pulses, ulcers with ascending cellulitis, and diabetic ulceration, accounting for 73.50% (n = 163), 71.60% (n = 159), and 66.70% (n = 148), respectively. The mean foot care prioritization score for the study participants was 54.1 (standard deviation: 11.7) out of 78 (69.4%), which demonstrates a moderately high level of foot care prioritization. Binary logistic regression analysis identified that healthcare professionals who are aged 35-44 years, those who have 5-10 years of experience, those who work at private hospitals, those who have a higher number of practice clinics per week, and those who have to manage a higher number of patients with diabetes in each clinic were more likely to prioritize foot care in their practices (p < 0.05). Our study found that healthcare professionals in Saudi Arabia place a moderate degree of emphasis on foot care. Healthcare professionals falling within the age range of 35-44 years, possessing 5-10 years of experience, employed at private hospitals, overseeing a greater number of practice clinics weekly, and managing a greater number of patients with diabetes per clinic exhibited a greater propensity to prioritize foot care within their respective practices. Policymakers should consider the integration of continuous glucose monitoring technologies, the establishment of standardized foot screening protocols, and the implementation of targeted educational programs for healthcare professionals.

A Multi‐Module Sensing and Bi‐Directional HMI Integrating Interaction, Recognition, and Feedback for Intelligent Robots

AbstractRapid advances in robotics have placed urgent demands on more intelligent human‐machine interaction technologies. Specifically, the way of establishing dual‐way intuitive communication with a consistent sensory system can greatly enhance efficiency and reliability. Here, a bi‐directional human‐machine interface (HMI) is designed by applying starch‐based hydrogel sensors. The whole system consists of a multi‐modal wearable sensory exoskeleton with a haptic feedback module and sensory robotic hand. The sensory exoskeleton with strain‐sensing glove and rotation‐sensing arm can capture and project the motion of the entire upper limb. The system offers object recognition functions by utilizing a sensing array on the robotic hands and machine learning algorithms, which can identify the shape and hardness information. The recognized results can be delivered back to the operator via vision and vibrational haptic feedback, respectively. This dual‐way intelligent sensory system shows potential application in many key fields such as the Internet of Things, teleoperation, and medical robotics.

Pelatihan Senam Pencegahan Osteoporosis dan Penyuluhan Kesehatan Gigi Mulut pada Masyarakat Pre dan Lanjut Usia Anggrek 3

Living a healthy life as a senior is the desire of everyone. However, keeping an elderly healthy is not easy. There are many challenges to face, because the elderly are susceptible to a variety of diseases. As you age, your body undergoes many changes or aging processes, and the changes you feel cover the entire limb. Vascular problems such as hypertension and other heart problems are common. Not only that, the elderly are also at risk of suffering from bone diseases such as osteoporosis, which can be dangerous because it can result in bone fractures and inhibit the activity of the elders because they have to lie more. Osteoporosis is often associated with periodontitis, as both are diseases of the bone caused by inflammation and old age. Both osteoporosis and periodontitis have similar risk factors such as smoking, poor nutritional status, age and immune deficiency. Osteoporosis can be prevented by eating foods rich in calcium, avoiding smoking and alcoholic beverages, having regular and regular physical activity, and exposure to sufficient sunlight. Preventing osteoporosis can reduce the risk of periodontitis in the elderly. This community service (PkM) is held for the elderly living in Grand Depok City Depok Residential, West Java. It is hoped that these activities will raise awareness of the elderly in particular, and the general public of the importance of health. It is expected that osteoporosis gymnastics for the elderly can be performed on a regular basis at Posbindu Anggrek 3.

Exploring the Indications, Levels, and Outcomes of Lower Extremity Amputation at a Tertiary Care Hospital in Pakistan.

Lower extremity amputation (LEA) is a surgical procedure performed to remove either a part or the entire lower limb due to medical conditions such as trauma, infection, peripheral vascular disease, or malignancy. The procedure is becoming increasingly common in Pakistan, with a bulk of patients presenting from rural areas in tertiary care centers. Understanding the indications, levels, and outcomes of LEA is essential for improving patient care and adopting preventive strategies, especially in developing countries. This study was conducted at Dow University Hospital in Karachi, Pakistan. Retrospective data of 384 patients who underwent non-traumatic lower extremity amputations between January 2016 and December 2020 was collected to include relevant history and characteristics, amputation indication and level, type of anesthesia used, and outcome within hospital stay. The data was analyzed using descriptive statistics. The data is composed of a wide age range (18 to 91 years) of patients, including a male majority (76.3%, n = 293). The employment status of the patients was taken into consideration, with a reported high number of unemployed individuals (60.4%, n = 232). Diabetes mellitus (84.4%, n = 324) was a commonly reported past medical condition, followed by hypertension (4.4%, n = 17). Indications for amputation exceedingly recorded were diabetic foot ulcers (84.4%, n = 324), followed by infections (9.4%, n = 36) and peripheral arterial disease (3.6%, n = 14). The anesthetic approach that was observed most in these patients was regional anesthesia (74.7%, n = 287). Right-sided amputations (52.9%, n = 203) were dominant, with below-knee amputations leading by the level of amputation performed (42.5%, n = 163). Many patients delayed seeking treatment (71.6%, n = 275) and indicated denial of severity (18%, n = 69) as a reason for the delay. Regarding outcome, many patients were successfully discharged following treatment (85.9%, n = 330). Overall, LEAs are being frequently performed in developing countries, such as Pakistan, especially with a large population living with diabetes mellitus. The implications of this disease are reflected in this study population, with the majority of patients reporting delays in treatment due to reasons such as the unknown severity of the disease or financial burdens. The challenges faced by these individuals, especially in this country, can be tackled with widespread affordability and availability of care and education on early management.

The added value of SPECT/CT lymphoscintigraphy in the initial assessment of secondary extremity lymphedema patients

An added value of SPECT/CT over planar lymphoscintigraphy for initial staging in patients with secondary extremity lymphedema was investigated. Furthermore, we developed a hybrid SPECT/CT classification combining dermal backflow (DBF) of SPECT and honeycomb pattern (HP) of CT, correlated it with lymphoscintigraphic staging and clinical severity. Forty-one patients with secondary extremity lymphedema who underwent lymphoscintigraphy with SPECT/CT were included retrospectively. The severity of extremity lymphedema was assessed using CT volumetry. Lymphoscintigraphic findings were evaluated using the Taiwan Lymphoscintigraphy Staging (TLS), and CT-based and SPECT-based quantitative analysis were performed. TLS was performed by planar scintigraphy only and with SPECT/CT, respectively. The SPECT/CT findings were classified into DBF−/HP−, DBF+/HP−, DBF+/HP+, and DBF−/HP+. Based on these findings, patients were categorized into five classes: Class 1 = DBF−HP− entire limb, Class 2 = DBF+/HP− proximal/distal limb without DBF+/HP+ or DBF−/HP+, Class 3 = DBF+/HP+ proximal/distal limb without DBF−/HP+, Class 4 = Mixed DBF+/HP+ and DBF−/HP+ in proximal/distal limb, Class 5 = DBF−/HP+ entire limb. Adding SPECT/CT to planar scintigraphy showed a 15.4% modification rate in lymphoscintigraphic staging. HP volume ratio significantly increased as clinical severity and lymphoscintigraphic staging increased, while DBF volume ratio increased with severity and followed expected patterns according to lymphoscintigraphic staging. Hybrid SPECT/CT lymphoscintigraphic classification showed strong positive correlation with clinical severity and TLS. Our results demonstrated substantial modification of lymphoscintigraphic staging by adding SPECT/CT to a conventional planar scintigraphy. In addition, a hybrid SPECT/CT is expected to provide new indicators reflecting lymphoscintigraphic staging and clinical severity by providing both of functional DBF and anatomical HP information.

Accuracy and safety of a new robotic arm for both femoral and acetabular side in total hip arthroplasty: a cadaveric study

BackgroundTo investigate the accuracy and safety of a newly constructed robotic arm which can cover the whole process of THA, we performed a series of robot-assisted total hip replacement on the cadaver.MethodsFifteen frozen cadaveric specimens (30 hips) were used for this study. In this investigation, united hip system and Longwell robotic-assisted system were used. The entire lower limb was CT scanned prior to surgery. The 3D model was produced based on CT data; the site of the prosthesis, including acetabular anteversion, inclination angle, and the position of femoral prosthesis, was planned. With the assistance of a robotic arm, the surgeon changed the parameters based on the preoperative plan and the actual condition during surgery, and completed the whole procedure. Following surgery, we measured the acetabular anteversion angle, acetabular inclination angle, femur anteversion angle, combined anteversion angle, stem angulation, and canal fill ratio.ResultsThe parameters proved that the acetabular anteversion angle was 16.85 ± 3.00°, the acetabular inclination angle was 40.38 ± 5.37°, femur anteversion angle was 15.90 ± 9.01°, combined anteversion angle was 32.75 ± 9.03°, stem angulation was 1.84 ± 0.99°, and leg length discrepancy was 2.47 ± 1.43 mm. The canal fill ratio (CFR) of femoral prosthesis of osteotomy line in sagittal section is 99.72 ± 1.54% and in coronal section is 62.94 ± 8.91%; below osteotomy line 2.5 cm in sagittal section is 100.00% and in coronal section is 81.48 ± 12.94%; below osteotomy line 7.5 cm in sagittal section is 59.51 ± 12.94% and in coronal section is 89.79 ± 11.13%; femoral shaft isthmus in sagittal section is 56.41 ± 13.80% and in coronal section is 84.95 ± 15.17%.ConclusionThe accuracy and safety of this novel robotic arm are suitable for preparing both the acetabular and femoral sides, providing evidence for clinical trial.

Classification of elbow stiffness

Stiffness is a clinical disorder that affects the patient’s function of the entire upper limb. Many classifications systems have been developed for elbow stiffness based on the plane of motion, severity, etiology, prognosis or anatomical location. A new classification, the Stiffness types and Influencing Factors (S.T.I.F.) Classification System, is proposed as treatment algorithm to guide the surgical treatment and the preferred operative approach (open or arthroscopic). IntroductionStiffness is a clinical disorder that affects the patient’s function of the entire upper limb. It can be caused by a variety of elbow disorders. The most common cause is post-traumatic; this category also includes burns, head injuries and elbow surgeries. However, elbow stiffness also can be caused by atraumatic etiologies, such as osteoarthritis, inflammatory joint disease, ulnar nerve entrapment, tumor, infection, metabolic disease (e.g., hemophilia) and congenital conditions (arthrogryposis).Being able to classify elbow stiffness is critical to understanding the etiology and planning the treatment strategy. ClassificationMany classification systems have been developed for elbow stiffness.

Pelvic coronal inclination change in adolescent flexible flatfoot surgically treated with arthroereisis

Objective: To evaluate adolescent pelvic coronal inclination angle change after flatfoot treated with arthroereisis. Method: A case-series study. From June 2018 to September 2020, 25 children with flexible flat foot and pelvic obliquity were included in this retrospective study in Peking University Shenzhen Hospital. There were 17 males and 8 females with a mean age of (11.2±2.2) years (9-15 years). There were 5 cases of unilateral flatfoot and 20 cases of bilateral flatfoot. All of the patients were surgically treated with arthroereisis. Regular follow-up was done in 3 months, 1 and 2 years postoperatively. Weightbearing fluoroscopy of entire lower limb and foot were investigated to measure Meary's angle, calcaneal pitch angle, height difference at ankle and pelvic plane, pelvic inclination and sacrum-iliac distance (F value) on coronal plane. Results: The mean Mearys' angle at 3 month postoperatively was improved when compared with that before the operation (3.1°±1.5° vs 25.9°±4.3°, P<0.001), and it remained at the same level 2 years after the operation (compared with that at 1 year after the operation, P=0.748). The calcaneal pitch angle improved significantly at 3-month follow-up when compared with that before the operation (16.6°±2.4° vs 9.9°±1.5°, P<0.001), and there was no significant change between 1 year and 2 years after operation (P=0.542). The height difference at mortise plane were also reduced at the 3-month follow-up(P<0.001), and it remained at the same level at 1 year and 2 years after the operation (P=0.159). Pelvic height difference decreased dramatically from (12.4±1.7) mm (before operation) to (7.1±1.2) mm(3 month after the operation) (P<0.001), it decreased to (3.6±1.8) mm 1 year after the operation (compared with that at 3 months after the operation, P<0.001), and no further reduction was observed 2 years after the surgery (P=0.483). The pelvic inclination angle and sacrum-iliac distance were also improved at 3-month follow-up when compared with those before the operation (both P<0.001), and they declined further 1 year after the operation(both P<0.05), but the decreasing trend disappeared at the 2-year follow-up (both P>0.05). Conclusion: For adolescent flexible flat foot patients with pelvic obliquity, the coronal inclination and pelvic height discrepancy would partially recovered with correction of flatfoot deformity, but it could not be completely corrected in the mean follow-up period of 2 years after the operation.

A self-managed exercise therapy program for wrist osteoarthritis: study protocol for a randomized controlled trial

BackgroundPost-traumatic wrist osteoarthritis (OA) can eventually lead to pain, muscular weakness, and stiffness of the wrist, which can affect the function of the entire upper limb and reduce the quality of life. Although there is strong evidence that all patients with OA should be offered adequate education and exercises as a first-line treatment, an effective self-management program, including structured education and therapeutic exercises, has not yet been introduced for individuals with wrist OA. This trial aims to evaluate the effectiveness of an exercise therapy program with joint protective strategies to improve neuromuscular control (intervention group) compared to a training program with range of motion exercises (control group).MethodsThis is a single-blinded randomized controlled trial (RCT) with two treatment arms in patients with symptomatic and radiographically confirmed wrist OA. The trial will be conducted at a hand surgery department. The participants will be randomly assigned either to a neuromuscular exercise therapy program or to a training program with range of motion exercises only. Participants in both groups will receive a wrist orthosis and structured education on wrist anatomy, pathophysiology, and joint protective self-management strategies. The programs consist of home exercises that will be performed twice a day for 12 weeks. The Patient-Rated Wrist Evaluation (PRWE) is the primary outcome measure of pain and function. Wrist range of motion (ROM), grip strength, the Numeric Pain Rating scale (NPRS), Disabilities of the Arm, Shoulder, and Hand (DASH), the General Self-Efficacy Scale (GSES), Global Rating of Change (GROC), and conversion to surgery are the secondary measures of outcome. Assessments will be performed at baseline and at 3, 6, and 12 months after baseline by a blinded assessor.DiscussionThe upcoming results from this trial may add new knowledge about the effectiveness of a self-managed exercise therapy program on pain and function for individuals with wrist OA. If the present self-management program proves to be effective, it can redefine current treatment strategies and may be implemented in wrist OA treatment protocols.Trial registrationClinicalTrials.gov, NCT05367817. Retrospectively registered on 27 April 2022. https://clinicaltrials.gov.

Characterizing Three-Dimensional Alignment of the Hip, Knee, Ankle and Foot under Physiological Upright Load. A Weight-Bearing Computed Tomography Study in Arthritic Joints and Healthy Controls

Category: Ankle Arthritis; Other Introduction/ Purpose: Lower limb alignment assessment is commonly performed using two-dimensional (2D) conventional- radiographs. Weight-Bearing Computed-Tomography (WBCT) imaging that allows concomitant 3D imaging of the hip, knee, ankle, and foot, a more complete and multidimensional assessment of the entire overall lower limb alignment is now possible. The aims of this study were: (1) to characterize the normal relative 3D alignment of the center of the Hip, Knee, and Ankle joints in relation to the weight bearing Foot Tripod in a cohort of healthy control volunteers with no lower extremity pathologies, using WBCT imaging. (2) to perform the same 3D WBCT assessment in a cohort of patients with either hip osteoarthritis (HOA), knee osteoarthritis (KOA) or ankle osteoarthritis (AOA), and to compare the results between arthritic cases and controls. Methods: Prospective comparative and controlled cohort-study contained 7 HOA limbs (4 patients), 17 KOA limbs (10 patients), 7 AOA limbs (4 patients) and 10 control limbs (5 patients) that received WBCT imaging of the full lower extremity. Using multiplanar reconstruction WBCT images, 3D landmark coordinates (on X, Y, and Z planes) were manually measured by two observers. The utilized software (CubeVue®) generated an automatic calculation of the Foot-Hip Offset (FHO), Foot-Knee Offset (FKO) and Foot and Ankle Offset (FAO). The relationship between the center of the hip, knee and ankle joints and the bisecting line of the foot tripod was assessed and compared between HOA, KOA, AOA patients and controls. Examples of measurements for arthritic patients and controls is presented in Figure 1. Continuous data was assessed for normality with the Shapiro-Wilk test, and variables were compared using ANOVA or Kruskal- Wallis Rank Sum. P-Values of less than 0.05 were considered significant. Results: The average FAO and 95%-Confidence-intervals-(CI) for respectively HOA, KOA, AOA and controls were respectively: 3.62% (0.4 to 6.8) (neutral), 2.8% (0.78 to 4.9) (neutral), -4.68% (-7.8 to -1.4) (varus), and 2.12% (-0.5 to 4.8) (neutral). The FAO- differences were found to be significant between the groups (p=0.0077), with AOA patients being significantly different than all the other groups (Figure 2). Similarly, the HFO was found to be significantly different-between the groups (p=0.002), with the following average values and 95%CI for respectively HOA, KOA, AOA and controls: 0.7% (-6.4 to 7.8), 2.3% (-2.3 to 6.8), -10.1% (-17.2 to -3.0), and 5.3% (-0.6 to 11.3). Again, the AOA patients were found to be significantly different than the other groups. No significant differences were found between the groups when assessing the KFO (p=0.37). Conclusion: The baseline 3D lower limb alignment and relative position of the hip, knee, ankle and foot was assessed and established for the first time in the literature. When comparing 3D alignment in arthritic patients with hip, knee or ankle OA and controls, we observed that AOA was found to be the one affecting more the overall 3D alignment of the lower extremity, with no complete compensation of the deformity through the other joints, resulting in significantly different values of HFO, KFO and FAO in patients with ankle OA. Additional prospective studies with longer cohorts of patients are needed.