Limb Function In Patients Research Articles

Split Flexor Carpi Ulnaris Transfer: A New Functioning Free Muscle Transfer with Independent Dual Function

A functioning free muscle transfer is a well-established modality of restoring upper limb function in patients with significant functional deficits. Splitting the neuromuscular compartments of the free muscle based on its intramuscular neural anatomy and using each compartment for a different function would allow for restoration of two functions instead of one at the new distant site. The authors previously reported on the clinical use of a pedicled split flexor carpi ulnaris muscle transfer. They now report the use of this muscle as a functioning free split muscle transfer to restore independent thumb and finger extension in a patient with total extensor compartment muscle loss in the forearm and a concomitant high radial nerve avulsion injury. Nine months postoperatively, the patient was able to extend his thumb and fingers independent of each other. This is the first report of a functioning free split muscle transfer demonstrating two independent functions in the upper limb.

Knee Joint Position Sense in Compressive Myelopathy

The knee joint position sense (JPS) and kinesthesia were measured in patients with compressive myelopathy. To find out how the knee JPS and kinesthesia are useful to evaluate lower limb function in patients with compressive myelopathy. No previous reports have been written on the quantitative analysis of knee joint proprioception in myelopathy patients. Twenty-one compressive myelopathy patients with a mean age of 64 years were studied. The measured values of JPS and kinesthesia were examined in relation to the following: lower limb function and central motor conduction time (CMCT). Inaccurate angles of the knee JPS in patients with severe walking disability were significantly larger than those in patients with mild disability. Inaccurate angles of the knee JPS in patients with severe sensory disturbance were significantly larger than those in patients with mild disturbance. CMCT showed a significant correlation to the knee JPS. The knee JPS was useful to evaluate lower limb function in patients with compressive myelopathy.

Ununited Diaphyseal Forearm Fractures with Segmental Defects: Plate Fixation and Autogenous Cancellous Bone-Grafting

With current techniques of plate-and-screw fixation, diaphyseal nonunions of the radius and ulna are unusual. The few reports that have been published have discussed the use of structural corticocancellous bone grafts for the treatment of atrophic nonunions that are associated with osseous defects. We reviewed the rate of union and the functional results in association with the use of plate-and-screw fixation and autogenous cancellous (nonstructural) bone grafts. Thirty-five patients with an atrophic ununited diaphyseal fracture of the forearm were treated with 3.5-mm plate-and-screw fixation and autogenous cancellous bone-grafting. A segmental osseous defect with an average size of 2.2 cm (range, 1 to 6 cm) was present in each patient. Twenty of the original fractures had been open. Eleven patients had had treatment of a deep infection before referral to us. The nonunion involved both forearm bones in eight patients, the radius alone in sixteen patients, and the ulna alone in eleven patients. The atrophic nonunion was associated with an open fracture in twenty patients, suboptimal fixation in twenty-two, a fracture-dislocation of the forearm in nine, and infection in eleven. All fractures healed without additional intervention within six months. Two patients had a subsequent Darrach resection of the distal part of the ulna for the treatment of arthrosis of the distal radioulnar joint. After an average duration of follow-up of forty-three months, the final arc of motion averaged 121 degrees in the forearm, 131 degrees at the elbow, and 137 degrees at the wrist, with an average grip strength of 83% compared with that of the contralateral limb. According to the system of Anderson and colleagues, five patients had an excellent result, eighteen had a satisfactory result, eleven had an unsatisfactory result (because of elbow stiffness related to associated elbow injuries in three and because of wrist stiffness in eight), and one had a poor result (because of malunion). When the soft-tissue envelope is compliant, has limited scar, and consists largely of healthy muscle with a good vascular supply, autogenous cancellous bone-grafting and stable internal plate fixation results in a high rate of union and improved upper limb function in patients with diaphyseal nonunion of the radius and/or ulna.

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke

Background There are a number of different approaches to physiotherapy treatment following stroke that, broadly speaking, are based on neurophysiological, motor learning and orthopaedic principles. Some physiotherapists base their treatment on a single approach, while others use a mixture of components from a number of different approaches. Objectives To determine if there is a difference in the recovery of postural control and lower limb function in patients with stroke if physiotherapy treatment is based on orthopaedic or neurophysiological or motor learning principles, or on a mixture of these treatment principles. Search methods We searched the Cochrane Stroke Group Trials Register (last searched May 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2005), MEDLINE (1966 to May 2005), EMBASE (1980 to May 2005) and CINAHL (1982 to May 2005). We contacted experts and researchers with an interest in stroke rehabilitation. Selection criteria Randomised or quasi-randomised controlled trials of physiotherapy treatment approaches aimed at promoting the recovery of postural control and lower limb function in adult participants with a clinical diagnosis of stroke. Outcomes included measures of disability, motor impairment or participation. Data collection and analysis Two review authors independently categorised the identified trials according to the inclusion and exclusion criteria, documented their methodological quality, and extracted the data. Main results Twenty-one trials were included in the review, five of which were included in two comparisons. Eight trials compared a neurophysiological approach with another approach; eight compared a motor learning approach with another approach; and eight compared a mixed approach with another approach. A mixed approach was significantly more effective than no treatment or placebo control for improving functional independence (standardised mean difference (SMD) 0.94, 95% confidence intervals (CI) 0.08 to 1.80). There was no significant evidence that any single approach had a better outcome than any other single approach or no treatment control. Authors' conclusions There is evidence that physiotherapy intervention, using a mix of components from different approaches, is significantly more effective than no treatment or placebo control in the recovery of functional independence following stroke. There is insufficient evidence to conclude that any one physiotherapy approach is more effective in promoting recovery of lower limb function or postural control following stroke than any other approach. We recommend that future research should concentrate on investigating the effectiveness of clearly described individual techniques and task-specific treatments, regardless of their historical or philosophical origin.

Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke.

There are a number of different approaches to physiotherapy treatment following stroke. Central to these are approaches based on 'neurophysiological' principles, 'motor learning' principles and 'orthopaedic' principles. To determine if there is a difference in the recovery of postural control and lower limb function in patients with stroke if physiotherapy treatment is based on orthopaedic or neurophysiological or motor learning principles, or on a mixture of these treatment principles. This review drew on the search strategy developed by the Stroke Group as a whole. Relevant trials were identified in the Stroke Group Trials Register of Controlled Trials which was last searched in May 2001. We also searched the Cochrane Controlled Trials Register (Cochrane Library, Issue 4 1999), MEDLINE (1966-1999), EMBASE (1980-1999) and CINAHL (1982-1999) and contacted experts and researchers with an interest in stroke. Studies - randomised or quasi-randomised controlled trials. Participants - adults with a clinical diagnosis of stroke. Interventions - physiotherapy treatment approaches aimed at promoting the recovery of postural control and lower limb function. Outcomes - measures of disability, motor impairment or participation. Two independent reviewers categorised the identified trials according to the inclusion/exclusion criteria, documented the methodological quality and extracted the data. Eleven trials were included in the review, three of which were included in two comparisons. Four trials compared a neurophysiological approach with another approach; four trials compared a motor learning approach with another approach; four studies compared a mixed approach with another approach; two trials reported comparisons of sub-groups of the same approach. A large number of heterogeneous outcome measures were used, limiting the comparison of trial results. No one type of approach had a significantly better outcome than any other type of approach. There is insufficient evidence to conclude that any one physiotherapy treatment approach is more effective than another in promoting the recovery of postural control or lower limb function.

Limb salvage for soft-tissue malignancies of the foot: an evaluation of free-tissue transfer.

Free flaps may safely allow meaningful ambulation, durable limb preservation, and better quality of life in patients undergoing resections of soft-tissue cancers of the foot. To prove this, the records of a series of patients at The University of Texas M. D. Anderson Cancer Center (n = 67) who underwent limb salvage following tumor-related resection (n = 71 procedures) from 1989 to 1999 were retrospectively reviewed. Eighteen patients who were not candidates for local flaps or skin grafts received a total of 20 free flaps to preserve their limbs. Most defects (mean size, 78 cm2; range, 20 to 150 cm2) were on a weight-bearing surface of the foot (nine on a weight-bearing heel, three on a plantar foot); the remainder were on a non-weight-bearing surface (six on dorsum, two on a non-weight-bearing heel). Melanoma was diagnosed in nine cases (50 percent); soft-tissue sarcoma, in seven (39 percent); and squamous cell carcinoma, in two (11 percent). Fasciocutaneous and skin-grafted muscle flaps were used on both weight-bearing and non-weight-bearing surfaces. Free-tissue transfer was successful in 17 of 20 cases (85 percent); the three flap losses occurred in two patients. Minor complications (i.e., small hematoma, partial skin graft loss, and delayed wound healing) occurred in five patients. In all cases of successful free-tissue transfer, patients began partial weight bearing at a mean of 7.4 weeks (range, 2 to 12 weeks), and all ultimately achieved full weight bearing. Sixty-seven percent still required special footwear. In one patient, an ulceration on the weight-bearing portion of the flap resolved after a footwear adjustment. Only one patient was lost to follow-up (mean, 23 months). In the 17 remaining patients, limb salvage succeeded in 15 (88 percent). Of these, nine (60 percent) were alive without evidence of disease, three (20 percent) were alive with disease, and three (20 percent) had died of disease. Local recurrence developed in two patients but was successfully treated by excision and closure. No late amputations were required for local control. Thus, it seems that free flaps help facilitate limb salvage and that they may preserve meaningful limb function in patients who undergo resection of soft-tissue malignancies of the foot.

Isometric torque about the knee joint generated by microstimulation of the cat L6 spinal cord.

Isometric torque was generated about the knee joint by microstimulation of the cat L6 spinal cord using a single microelectrode. The torque responses varied with microstimulation location. Appreciable extension torque was generated by microstimulation in ventrolateral locations of the L6 spinal cord. Stimulation parameters (intensity, frequency and pulse-width) also influenced the extension torque. Specific stimulation parameters (100 microA intensity, 40 Hz frequency and 0.20 ms pulse-width) appear best suited for mapping the spinal cord based on knee joint torque responses. Low levels of cocontraction of the extensor and flexor could be achieved when extension torque was produced, but also varied with the stimulation locations. There are locations in the L6 ventral horn where microstimulation could evoke sustained extension for at least 4 min with only a slight change in torque. This study suggests the possibility of restoring lower limb function in patients with spinal cord injury above the lumbar level.

Combined Surgery and Radiation Therapy for Limb Preservation in Soft Tissue Sarcoma of the Extremity: The Massachusetts General Hospital Experience

The results presented here indicate that excellent local control rates can be achieved using radiation in combination with limb-sparing surgery. At least three challenges remain and need to be addressed in future prospective trials. One is the need to reduce wound complications. In this regard, the influence of chemotherapy on the healing of the irradiated wound needs to be better defined as well as the role of recombinant growth factors and cytokines in tissue repair. Second is the need to better assess functional and psychological outcome in patients who are long-term survivors as well as in patients who succumb to distant disease. Despite the limited information on this end-point, it appears that strategies that reduce wound morbidity ultimately have a beneficial outcome with regard to functional and psychological status. Third, our greatest challenge is to improve the rates of distant disease control. Despite excellent local control rates following limb-sparing procedures, greater than 50% of patients will ultimately die of their disease. New systemic therapies must be developed to control systemic dissemination. The ultimate goal of combined surgery, radiation, and chemotherapy will be to preserve limb function in patients who are cured of their disease.

A new therapeutic modality involving acridine orange excitation by photon energy used during reduction surgery for rhabdomyosarcomas

Rhabdomyosarcoma is a common malignant soft tissue that frequently involves bone and major neurovascular structures and resection of deep-seated rhabdomyosarcoma can cause severe dysfunction in the affected limbs. Based on the mouse osteosarcoma model, we developed a new surgical approach involving photodynamic surgery (PDS), photodynamic therapy (PDT) and radiodynamic therapy (RDT) using acridine orange (AO). Six rhabdomyosarcoma cases were treated using this new modality after confirming the effectiveness of AO-PDT on human rhabdomyosarcoma cell lines. All patients had almost normal limb function after surgery, with only one recurrence. Based on these results, AO-PDS, PDT and RDT can be used to preserve excellent limb function in patients with rhabdomyosarcoma involving major nerves and vessels or bones.