Soft Tissue Contracture Research Articles

Does Short-term Application of an Ilizarov Frame with Transfixion Pins Correct Relapsed Clubfoot in Children?

Treatment of relapsed clubfoot after soft tissue release in children is difficult because of the high recurrence rate and related complications. Even though the Ilizarov method is used for soft tissue distraction, there is a high incidence of recurrence after removal of the Ilizarov frame owing to previous contracture of soft tissue and a skin scar. We asked (1) whether transfixation of midfoot joints by temporary K wires during the consolidation stage after short-term application of an Ilizarov frame would maintain correction of the relapsed clubfoot clinicoradiologically and (2) whether this method would reduce the rate of recurrence and related complications in patients with a skin scar from previous surgery. We retrospectively reviewed 18 patients (19 feet) with relapsed clubfeet who underwent correction by soft tissue distraction using an Ilizarov ring fixator, between March 2005 and June 2008. The mean age of the patients was 8 ± 2 years (range, 4-15 years). K wire fixation for the midfoot joints combined with a below-knee cast were used during the consolidation stage. The minimum followup was 2 years (mean, 4.5 years; range, 2-6 years). The average duration of frame application was 5 weeks; the mean duration of treatment was 11 weeks. At last followup, 16 of 19 feet were painless and plantigrade and only three of 19 feet had recurrence. The mean preoperative clinical American Foot and Ankle Society (AOFAS) score had increased at last followup (57 versus 81). The values of the AP talocalcaneal, AP talo-first metatarsal, and lateral calcaneo-first metatarsal angles improved after treatment. The three recurrent clubfeet were treated by corrective osteotomies and Ilizarov frame application. This method could maintain the correction of relapsed clubfoot in children and reduce the recurrence rate and complications regardless of the presence of a skin scar owing to previous surgery.

Management of hip contractures and dislocations in arthrogryposis

Arthrogryposis represents a group of heterogeneous disorders, characterized by contractures of multiple joints at birth. Involvement of the hip is very common (55-90% of patients) ranging from soft tissue contractures to subluxation and dislocation. Isolated contracture of the hip can usually be managed conservatively: compensative mechanisms and contractures of other joints should be evaluated before planning surgery. For unilateral dislocations, open reduction is indicated to provide a level pelvis, even though the risk of stiffness, avascular necrosis and redislocation is significant. Indications for surgical reduction of bilateral dislocations are more controversial: an adequate evaluation of ambulatory potential of the child (muscular weakness, involvement of upper extremities, etc.) and of stiffness of the hips is suggested. An extensive and long-lasting programme of bracing, physiotherapy and multiple surgery may lead to some measure of functional ambulation in most cases, but high need for surgery and considerable risk of complications must be considered. This paper summarizes problems and principles of treatment for hip contractures and dislocations in arthrogryposis and provides a review of the current literature.

Suprascapular neuropathy caused by heterotopic ossification after clavicle shaft fracture: a case report.

Suprascapular neuropathy is a rare peripheral neuropathy that can be easily overlooked in the differential diagnosis of shoulder pain and dysfunction. The suprascapular nerve may be injured as a result of repetitive overuse, constriction due to anatomic variants, compression due to space occupying lesions, retraction due to a massive rotator cuff tear and iatrogenic or traumatic lesions. Trauma-related suprascapular neuropathies are often caused by glenohumeral joint dislocations, scapular fractures, proximal humeral fractures, penetrating injuries and displaced clavicle fractures. Although many causes of suprascapular neuropathy have been described, there have been few reports of suprascapular neuropathy caused by heterotophic ossification after trauma around shoulder. Heterotophic ossification is the formation of bone in non-skeletal tissue, usually between the muscle and joint capsule. It usually occurs following trauma, surgery, burns, fractures, dislocation or soft tissue trauma. The spectrum of heterotophic ossification ranges from incidental radiographic findings to severe functional limitations. The range of motion can be decreased, resulting in soft tissue contractures. It can also cause peripheral neuropathy by impinging adjacent nerves. 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 significant complications. We report a very unusual case of suprascapular neuropathy that resulted from heterotophic ossification after clavicle shaft fracture. This case was treated by open excision of the heterotophic ossification and external neurolysis of the suprascapular nerve. Although the incidence is very low, the heterotophic ossification should be considered as a possible cause of suprascapular neuropathy.

Measures of pediatric function: Child Health Assessment Questionnaire (C‐HAQ), Juvenile Arthritis Functional Assessment Scale (JAFAS), Pediatric Outcomes Data Collection Instrument (PODCI), and Activities Scale for Kids (ASK)

Children with a rheumatic disease frequently experience impairments in one or more body systems; these may include pain, stiffness, fatigue, muscle weakness, soft tissue contractures, and poor exercise capacity. These impairments may directly limit the child’s ability to perform some physical activities or may do so indirectly if the child or parent fears such activities may cause injury or a disease flare. It is essential to understand the impact of rheumatic disease on a child’s activities in order to guide intervention and monitor changes in functional abilities over time and with targeted therapies. This is especially important when disease onset occurs at a very young age because the long-term effects of physical limitations can negatively impact the child’s quality of life. The best measure of activities for a particular child or group of children depends on the context of the evaluation, including the physical and social environment. For example, a child may perform a task like standing up from the floor without assistance in a quiet, standardized environment like the clinic, but does not perform the same task during physical education class at school or after a fall in the community. Holsbeeke et al (1) suggest there are 3 related but separate constructs of physical activity that are distinguished by this person-environment interaction. Capacity describes what a person can do in a standardized controlled environment, capability describes what a person can do in his/her daily environment, and performance describes what a person actually does in his/her daily environment. Four measures of physical activities that have been developed for or are appropriate for use in children with a rheumatic disease will be reviewed. Only the Juvenile Arthritis Functional Assessment Scale (JAFAS) and the Childhood Health Assessment questionnaire (C-HAQ) were developed specifically for children with juvenile arthritis. The C-HAQ, the most frequently used measure of activities in pediatric rheumatology, evaluates a child’s capability to perform activities in their daily environment, while the JAFAS measures the child’s capacity in the daily environment. Both the Activities Scale for Kids (ASK) and the Pediatric Outcomes Data Collection Instruments (PODCI), although not specifically designed for use in pediatric rheumatic diseases, assess physical function in children with chronic health disorders, including childhood arthritis. The ASK includes 2 versions, one that measures a child’s physical capability in his/her daily environment (ASKc) and one that measures the child’s performance of the same activities in their daily environment (ASKp). The ASK is also the only measure that requires the child to be the respondent because, as Young et al (2) state, “it is the child who is most familiar with his or her own abilities or limitations in each setting.” Finally, the PODCI, the most comprehensive of the 4 instruments, measures capability primarily, and includes a pediatric version to be completed by a parent and an adolescent version that can be completed by the parent, child, or both. Each of these 4 measures includes activities that are necessary and important to children across a wide age range. The use of 2 or more of these measures in combination may provide clinicians with the best understanding of a child’s typical activities and participation in age-appropriate settings.

Soft Tissue Design - A New Application for CMF Planning Software iPlan

Injuries to the face from trauma or tumor surgery sometimes lead to loss of facial structures such as eyes, ears and nose. Loss of these structures is disfigurative and may cause the patient a social handicap. Reconstruction of lost tissue with an epithesis has been used for many years. During this time, the most important factor for a successful cosmetic result has been the artistic ability of the anaplastologist to create a mirrored image of the healthy side. One of the major problems in making the epithesis is correct placement of the epithesis to achieve restored symmetry of the face. Over the years different aids in placing the epithesis have been utilized, for example the symetrograph (Reumuth et al, 1965) and later projection of an inverted photo over a plaster cast of the defect (Frenkel, 1970). Another problem is that conventional impression technique may deform soft tissues due to pressure of the impression material and subsequently cause discomfort to the patient. Technical advances with computed tomography (CT), magnetic resonance imaging (MRI), laser scanners and structured light techniques together with surgery planning software have enabled 3-dimensional reconstructions of the facial anatomy (Kau et al, 2007). These techniques may facilitate both design and manufacture of facial epithesis (Feng et al, 2009). iPlan is a software mainly intended for preoperative planning of CMF reconstructive navigation guided bone surgery. 3D models have during recent years proven useful for preoperative evaluation and operation planning. The present case illustrates a new application for iPlan (iPlan v.3.0; Brainlab AG, Feldkirchen, Germany), with the possibility for soft tissue-based computer aided design of an orbital epithesis. A 95-year-old man previously was treated for a recurrent basal cell carcinoma with removal of his left eye followed by radiotherapy. For many years the patient has used an orbital prosthesis but due to soft tissue contraction and further surgery due to recurring tumor he now was a candidate for an epithesis. Implant placement was not considered an option due to poor tissue quality and the patient's general health. As a part of regular tumor treatment follow up a CT scan was made. The DICOM images were processed in the iPlan software and soft tissue profile of the face was analyzed. To create facial symmetry the unaffected healthy side was aligned and mirrored over the defect on the left side. Subsequently the mirrored right side was subtracted from the left side profile leaving a volume difference representing the design of the epithesis. The epithesis was exported in STL-format and a plaster model was printed in a 3D printer (Zprint 450; Z Corporation, Burlington, MA). The model was then used by the anaplastologist to shape and model the final silicone epithesis. Retention of the epithesis was excellent. The new application of soft tissue-based design was shown a useful tool in restoring facial symmetry and placement of an orbital epithesis. One limitation of this method is however that it is based on an x-ray investigation and that it may be difficult to obtain a normal relaxed posture with open eyes during such procedure.

Total hip replacement for high dislocated hips without femoral shortening osteotomy

When performing total hip replacement (THR) in high dislocated hips, the presence of soft-tissue contractures means that most surgeons prefer to use a femoral shortening osteotomy in order to avoid the risk of neurovascular damage. However, this technique will sacrifice femoral length and reduce the extent of any leg-length equalisation. We report our experience of 74 THRs performed between 2000 and 2008 in 65 patients with a high dislocated hip without a femoral shortening osteotomy. The mean age of the patients was 55 years (46 to 72) and the mean follow-up was 42 months (12 to 78). All implants were cementless except for one resurfacing hip implant. We attempted to place the acetabular component in the anatomical position in each hip. The mean Harris hip score improved from 53 points (34 to 74) pre-operatively to 86 points (78 to 95) at final follow-up. The mean radiologically determined leg lengthening was 42 mm (30 to 66), and the mean leg-length discrepancy decreased from 36 mm (5 to 56) pre-operatively to 8.5 mm (0 to 18) postoperatively. Although there were four (5%) post-operative femoral nerve palsies, three had fully resolved by six months after the operation. No loosening of the implant was observed, and no dislocations or infections were encountered. Total hip replacement without a femoral shortening osteotomy proved to be a safe and effective surgical treatment for high dislocated hips.

Inpatient occupational therapists hand-splinting practice for clients with stroke: A cross-sectional survey from Ireland

Introduction:Hand splinting after stroke is a common practice despite inadequate evidence. This warrants a better understanding of the therapists’ splinting practice, to develop clinically meaningful treatment options.Aims:The study examined the nature and prevalence of the factors associated with therapists’ hand splinting practice and their perceived splinting efficacy.Settings and Design:A cross-sectional national survey of hand-splinting practice among inpatient occupational therapists (OTs) in Ireland.Materials and Methods:Sixty-two therapists participated in this national survey.Statistical analysis usedA number of factors were analyzed to explore their relationship with therapists’ perception of splint efficacy using Spearman's rank order correlation.Results:53(85.5%) out of 62 survey respondents prescribed splints to their clients at the time of taking the survey. To reduce spasticity, to correct contractures and thus increase range of motion (ROM) were the commonly used splinting goals. These were the goals that were significantly associated with the therapists’ splinting efficacy too.Conclusions:Hand-splint prescription following stroke was found to be a common practice among OTs who perceive splints to be quite effective. A custom-made, volar forearm-based wrist-hand splint is the preferred splint among therapists to achieve a number of clinical aims such as improving ROM, stretching soft tissue contractures and reducing spasticity in the upper extremity. A wide variety of splinting regimens is currently practiced, reflecting the lack of a universally accepted and comprehensive practice guideline to regulate therapy. Methodologically valid clinical trials evaluating the efficacy of therapist-preferred splints in achieving their favored outcomes are needed. Development of common, universally accepted therapeutic guidelines based on comprehensive scientific review of such studies is thus needed.

9- ONE STAGE COMBINED SURGICAL TREATMENT FOR DEVELOPMENTAL DISLOCATION OF THE HIP IN OLDER CHILDREN INCLUDING FEMORAL SHORTENING

Ali A Al-Iedan MBChB, CABS, Lecturer in Orthopaedics, Department of Surgery, College of Medicine, University of Basrah, Basrah – Iraq. Abstract The treatment of developmental dislocation of the hip (DDH) in older children is a challenge because they have high displacement of the hip, contracted soft tissues, insufficiency of the acetabulum and increased anteversion of the femoral head. In such patients it is difficult to reduce the femoral head into the acetabulum, maintain the concentric reduction and obtain a satisfactory functional hip joint. The aim of this study is to assess the advantage and disadvantage of one stage combined surgery with femoral shortening in treatment of DDH in children above 2 years old. This is a prospective study done in Al-Basrah General Hospital between (June 2008-June 2010), thirty patients were treated (35 hips), 28 females and 2 males. Five hips were right hip dislocation, 20 hips were left and 5 patients were bilateral. Femoral shortening done for all the hips and, in 28 hips pelvic osteotomy were performed at the time of open reduction. At the most recent follow-up (4 months-2 years) According to the radiographic criteria of Severin, 5 hips were excellent, 15 hips good and 10 hips have fair results, 5 end up hips had poor outcome. Avascular necrosis developed in 5 of the 35 hips. All patients were followed with respect to range of motion and recovery from limb-length discrepancy. Different complications were recorded per or postoperatively. Some complications like pelvic fracture (1 hip), subluxation and instability (3 hips), dislocation (2 hips) and stiffness (7 hips). According to the rating system of Mckay's clinical criteria, there were 7 hips excellent, 11 hips good, 12 hips fair results and 5 hips had a poor result. It is concluded that children who are two years or older and have DDH, can safely be treated with an extensive one-stage operation consisting of open reduction combined with femoral shortening and pelvic osteotomy, without increasing the risk of avascular necrosis. The limb length discrepancy that is produced by the shortening does not appear to cause a clinical problem.

The influence of age on timing of single-event multilevel surgery: are adolescents with cerebral palsy comparable to a younger cohort?

We are grateful to Švehlík et al.1 for providing some useful information on the long-term results of single-event multilevel surgery to improve gait in children with cerebral palsy, and for comparing two populations based on age. Although both groups improved substantially in their gait parameters postoperatively, the younger group saw some deterioration at their 10-year evaluation. However, the two groups are different in more than their age, as the authors point out. The younger patients had more soft tissue procedures and the older patients had more bony procedures. This would mean that the younger patients had more muscle activation and muscle length issues (i.e. contracture) than the older patients had when they were at that same age (or else those patients would have had soft tissue surgery when they were younger and been included in the younger group). Additionally, the older patients had more deformity and perhaps less muscle length and activation issues based on the procedures that they received, i.e. more bony procedures and fewer soft tissue lengthenings. This begs the question: is poor ambulation as a result of primarily bony deformity in an older child the same as poor ambulation as a result of muscular length and activation issues in a younger child? Probably not. The authors further note that the younger patients were all yet to experience their adolescent growth spurt and the older patients were either through, or in the midst of, their growth spurt at the time of their surgery and rehabilitation. The resulting limb growth that the younger group subsequently experienced is a major contributor to potential recurrence of soft tissue contracture in younger patients. Yet despite this, the number of follow-up operations was the same in the older group as it was in the younger group. Looking closer at the raw scores of the Gillette Gait Index, we find that the mean of the younger group decreased from 1657 to 613 at 10 years (a decrease of 63%), while the older group had a mean score that decreased from 1518 to 483 (a decrease of 68%) over that same time period. While statistically the younger children only reach a p value of 0.076 at 10 years, with the raw numbers as good as they are one cannot help but wonder if more patients would show that both groups maintained statistically significant improvement at 10 years post surgery. (The 7- to 8-y result had far smaller numbers so I would not draw any conclusions about that time period.) However, the article very nicely points out that children can see excellent results of well-done surgical intervention for ambulation at either the younger or older age. The types of surgery differ, but the follow-up surgeries are the same and improvement is maintained, although to a greater degree in those that will not require surgery until they are older. A child needs surgery when the gait has deteriorated sufficiently or failed to improve due to a soft tissue length or activation issue, or bony deformity. Some children require this early, some require it later. These are different children and one cannot simply postpone surgery until later and expect the same result when that child is older. These children represent different manifestations of cerebral palsy and this well conducted study shows us the difference between these groups of children.

The effects of intramuscular tenotomy on the lengthening characteristics of tibialis posterior: High versus low intramuscular tenotomy

BackgroundLengthening of soft-tissue contractures is frequently required in children with a wide variety of congenital and acquired deformities. However, little is known about the biomechanics of surgical procedures which are commonly used in contracture surgery, or if variations in technique may have a bearing on surgical outcomes. We investigated the hypothesis that the site of intramuscular tenotomy (IMT) within the muscle–tendon-unit (MTU) of the tibialis posterior (TP) would affect the lengthening characteristics.MethodsWe performed a randomized trial on paired cadaver tibialis posterior muscle–tendon-units (TP-MTUs). By random allocation, one of each pair of formalin-preserved TP-MTUs received a high IMT, and the other a low IMT. These were individually tensile-tested with an Instron® machine under controlled conditions. A graph of load (Newtons) versus displacement (millimetres) was generated for each pair of tests. The differences in lengthening and load at failure for each pair of TP-MTUs were noted and compared using paired t tests.ResultsWe found 48% greater lengthening for low IMT compared to high IMT for a given load (P = 0.004, two tailed t test). Load at failure was also significantly lower for the low IMT. These findings confirm our hypothesis that the site of the tenotomy affects the amount of lengthening achieved. This may contribute to the reported variability in clinical outcome.ConclusionsUnderstanding the relationship between tenotomy site and lengthening may allow surgeons to vary the site of the tenotomy in order to achieve pre-determined surgical goals. It may be possible to control the surgical “dose” by altering the position of the intramuscular tenotomy within the muscle–tendon-unit.

Hand kinematics: Application in clinical practice

ABSTRACTPathological conditions of the hand consequent to injuries, paralysis, disease, arthritis and congenital difference results in loss or limitation of function, deformities, stiffness, inadequate power and poor position for pinch. The pathogenesis of deformities is influenced by bio-mechanical principles of joints and muscle function. The crippling impact of secondary changes due to edema, soft tissue contractures, muscle shortening and functional adaptations also have a mechanical basis. For clinicians and hand therapists, it is necessary to understand these fundamental principles of biomechanics to plan treatment modalities. Interpretation of mechanics of hand deformities in rheumatoid arthritis and paralysis will enable the treating team to identify the appropriate interventions of splinting, therapy and surgical procedures. Basic knowledge of the principles of hand clinical bio-mechanics will help the beginner to sail through the multitude of tendon transfers described in the text books of hand surgery and find the best solution for a particular clinical presentation. Similarly, knowledge of bio-mechanics will provide solutions to an experienced surgeon to plan treatment protocols for complex situations. The article presents a concise summary of the basic principles of hand bio-mechanics for common hand conditions seen in clinical practice. Understanding and applying these principles will help clinicians in planning and devising treatment options for common and complex hand conditions.

Clinical-radiographic and histological evaluation of two hydroxyapatites in human extraction sockets: a pilot study

After tooth extraction the healing process involves bone resorption and soft tissue contraction, events that can compromise the ideal implant placement with functional and aesthetic limitations. Following tooth extraction, a socket preservation technique can limit bone resorption. This study evaluated two different types of hydroxyapatite (HA) grafting materials placed into fresh extraction sockets, 6 months after tooth extraction, histologically, clinically and radiographically. Ten extraction sockets from 10 patients were divided in two groups: 5 sockets received a biomimetic HA and 5 received nanocrystalline HA. After 6 months, before implant placement, samples from the grafted area were harvested and evaluated clinically, radiographically and histologically. The percentages of bone, osteoid areas and residual material in the two groups were not statistically different. All samples showed great variability with extensive bone formation and total material resorption or amounts of osteoid tissue that filled the spaces between the residual material particles. The authors did not find any differences between biomimetic and nanocrystalline HA and assume that, within the limits of this study, both these materials could be applied into fresh extraction sockets to limit bone resorption. A control material and a much larger sample size are needed to confirm these findings.

Facial Fractures

Fractures of the facial skeleton can result in the loss of an aesthetically pleasing appearance and basic function, and many cases subsequently require an operative intervention. The surgeon managing these facial fractures must, at the same time, be cognizant of concomitant injuries, including neurologic, ophthalmologic, and cervical spine issues. For most situations, early stabilization in anatomical position using rigid fixation will give the most accurate reduction for the optimal return of preoperative appearance and function, while reducing long-term soft-tissue contracture.

Shoulder sequelae of neonatal brachial plexus injuries: Orthopedic assessment and management

Brachial plexus birth palsy occurs at a rate of 1/1000-4/1000 live births despite advances in prenatal and obstetric care. The majority of children recover spontaneously, however some are left with permanent neurologic deficit. Shoulder pathology results from muscle imbalance created by pairing of weak or paralyzed muscles with unaffected muscle groups around the shoulder. This imbalance results in soft tissue contracture and can cause progressive glenohumeral joint morphological changes. Contractures of internal rotation are most common and may be a source of disability for the child. Treatment of the infant with brachial plexus palsy is initially centered around therapy and prevention of contracture. Surgical intervention can improve global shoulder function, and is reserved for patients who develop functionally limiting contractures, glenohumeral joint morphological changes, or findings of instability. A thorough physical examination, appropriate imaging, and assessment of the goals and expectations of the family are warranted prior to proceeding with any treatment course. The progressive and functionally limiting course of the shoulder sequelae in brachial plexus palsy emphasizes the need for early recognition and appropriate management. The purpose of this manuscript is to review orthopedic evaluation and management of neonatal brachial plexus palsy (NBPP) to promote early recognition and prompt referral.

Fundamental Principles in Aesthetic Rhinoplasty

This review article will highlight several fundamental principles and advances in rhinoplasty. Nasal analysis has become more sophisticated and thorough in terms of breaking down the anomaly and identifying the anatomic etiology. Performing this analysis in a systematic manner each time helps refine these skills and is a prerequisite to sound surgical planning. Dorsal augmentation with alloplastic materials continue to be used but more conservatively and often mixed with autogenous grafts. Long term outcomes have also taught us much with regards to wound healing and soft tissue contracture. This is best demonstrated with a hump reduction where the progressive pinching at the middle vault creates both aesthetic and functional problems. Correcting the twisted nose is challenging and requires a more aggressive intervention than previously thought. Both cartilage and soft tissue appear to have a degree of memory that predispose to recurrent deviations. A complete structural breakdown and destabilization may be warranted before the nose is realigned. This must be followed by careful and meticulous restabilization. Tip refinement is a common request but no single maneuver can be universally applied; multiple techniques and grafts must be within the surgeon's armamentarium.

The Modified Static Spacers Using Antibiotic-Impregnated Cement Rod in Two-Stage Revision for Infected Total Knee Arthroplasty

The two-stage exchange arthroplasty (one- or two-stage) is believed to be the gold standard for the management of infections following total knee arthroplasty. We herein report a novel two-stage exchange arthroplasty technique using an antibiotic-impregnated cement intramedullary nail, which can be easily prepared during surgery using a straight thoracic tube and a Steinmann pin, and may provide additional stability to the knee to maintain normal mechanical axis. In addition, there is less pain between the period of prosthesis removal and subsequent reimplantation. Less soft tissue contracture, less scar adhesion, easy removal of the cement intramedullary nail, and successful infection control are the advantages of this technique.

Hand kinematics: Application in clinical practice

Pathological conditions of the hand consequent to injuries, paralysis, disease, arthritis and congenital difference results in loss or limitation of function, deformities, stiffness, inadequate power and poor position for pinch. The pathogenesis of deformities is influenced by bio-mechanical principles of joints and muscle function. The crippling impact of secondary changes due to edema, soft tissue contractures, muscle shortening and functional adaptations also have a mechanical basis. For clinicians and hand therapists, it is necessary to understand these fundamental principles of biomechanics to plan treatment modalities. Interpretation of mechanics of hand deformities in rheumatoid arthritis and paralysis will enable the treating team to identify the appropriate interventions of splinting, therapy and surgical procedures. Basic knowledge of the principles of hand clinical bio-mechanics will help the beginner to sail through the multitude of tendon transfers described in the text books of hand surgery and find the best solution for a particular clinical presentation. Similarly, knowledge of bio-mechanics will provide solutions to an experienced surgeon to plan treatment protocols for complex situations. The article presents a concise summary of the basic principles of hand bio-mechanics for common hand conditions seen in clinical practice. Understanding and applying these principles will help clinicians in planning and devising treatment options for common and complex hand conditions.

Clubfoot in children

Clubfoot, or talipes equinovarus, is a deformity consisting of equinus, varus, and adductus foot deformity. The true etiology of congenital clubfoot is unknown; several theories have been proposed. The pathology of the individual bones contributes to the clubfoot deformity and soft tissue contractures around the ankle and talocalcaneonavicular joint maintains the deformity and involve muscles, tendons, tendon sheaths, ligaments and joint capsules. Various treatment regimens have been proposed, including the use of corrective splinting, taping, and casting. Surgery in clubfoot is indicated for deformities that do not respond to conservative treatment by serial manipulation and casting. Surgery in the treatment of clubfoot must be tailored to the age of the child and to the deformity to be corrected. The main goals of treatment is the painless, functional and anatomical normal foot without need for custom made footwear, and those can be achieved after detailed, indivudial approach with great experience in pediatric orthopedics.

Biomechanical assessment of brachioradialis pronatorplasty

Transfer of the brachioradialis muscle, proposed by Özkan et al. can be applied to cases, in which, the biceps rerouting technique is not appropriate for the correction of forearm supination contracture and restoration of active pronation. We have aimed to assess the biomechanical effects of the brachioradialis transfer. Pronation strength was acquired in nine fresh-frozen cadaver forearms by applying rerouting of the brachioradialis muscle through interosseous membrane (Group 1) or transferring the same muscle to the distal insertion of extensor carpi ulnaris (ECU) (Group 2). Then, a force of 5 to 35 N was applied to the muscle and the range of forearm rotation and rotation strength were measured. The normalities of the data were analyzed by Shapiro-Wilk test. Comparisons between the groups were made with independent-sample t-test and comparison of the data, obtained from the same group, was carried out with paired-sample t-test and Bonferroni correction. A maximum of 74° (with a mean of 61°) gain of pronation with rerouting and a maximum of 72° (with a mean of 65°) gain with ECU transfer of brachioradialis muscle were observed. A significant regression was also found in the first group. Regression constant was - 9.59 (p = 0.001, 95%: -13.20; -6.00) for the applied force of 2.06 N (p = 0.001, 95%: 1.90; 2.22). Furthermore, a significant regression was found in the second group. Regression constant was - 9.73 (p = 0.001, 95%: -13.13; -6.34) for the applied force of 1.91 N (p = 0.001, 95%: 1.76; 2.06). The brachioradialis muscle works as a pronator in full forearm supination. However, when the forearm comes close to the neutral rotation, due to the lateral location of the proximal insertion, the brachioradialis muscle loses this pronator effect. The additional release or lengthening of contracted soft tissues increases the range of pronation.

Lower limb coordination patterns in hemiparetic gait: Factors of knee flexion impairment

Background The mechanisms altering knee flexion in hemiparetic gait may be neurological (muscle overactivity) or orthopedic (soft tissue contracture) in nature, a distinction which is difficult to ascertain clinically during gait. This study aimed to distinguish the 2 mechanisms in evaluating thigh–shank coordination, which may show instability across the gait cycle in the case of bursting rectus femoris overactivity. Methods We measured thigh–shank coordination in the sagittal plane using the continuous relative phase during gait in 15 healthy subjects without and with an orthotic knee constraint (control and constrained) and 14 subjects with hemiparesis and rectus femoris overactivity before (pre) and after botulinum toxin injection. Findings Compared with the control group, both orthopedic and neurological knee flexion limitations were associated with decreased root-mean square of continuous relative phase over swing (control, 72.9; constrained, 26.0, P < 0.001; pre, 31.3, P < 0.001). However, only the neurological limitation was characterized by a higher number of continuous relative phase reversals over swing (control, 2.3; pre, 4.0; P = 0.001) and late stance (control, 0.6; pre, 1.7; P < 0.001). Botulinum toxin injection was associated with a 40% increase in root-mean square of continuous relative phase during swing and a 41% decrease in number of continuous relative phase reversals during late stance, while peak knee flexion was increased by 31%. Interpretation In hemiparesis, rectus femoris overactivity at swing phase is associated with alternating thigh–shank coordination in swing and late stance, which improves after botulinum toxin injection. Coordination analysis may help to distinguish neurological from orthopedic factors in knee flexion impairment.