Abstract
Introduction Traumatic brain injury (TBI) and / or spinal cord injury (SCI) usually occur in a polytraumatic context, and may produce catastrophic central nervous system (CNS) damages and secondarily extensive dysfunctional biomechanical alterations. This study aims to illustrate the interdisciplinary collaboration between neurorehabilitation and orthopedic clinics in our hospital, focusing on the results of surgical interventions intended to correct the fixed-flexion deformity of knees, in patients with disabling sequelae after CNS severe lesions.
Material and methods Between 2005-2018, in the Neuromuscular Rehabilitation Clinic of Teaching Emergency Hospital "Bagdasar-Arseni", 13 young patients (mean age 37.4 +/- 12.6; median 31; limits 26-43) with multiple articular stiffness and joint deposturing sequelae after severe CNS trauma have been transferred from other medical units. Twelve had bilateral knee flexion contractures, two associated additional elbow stiffness, and in three patients ectopic ossifications of the hips, with ankylosis in extension or painful flexion were found. Patients were subsequently transferred for iterative orthopedic interventions: hamstring lengthening (pes anserinus and femoral biceps tendon transpositions) in 12 cases, associated with posterior knee capsulotomy, traction and/or resection of neurogenic heterotopic ossification around the knee or hip joints and casting in 8 of them.
All orthopedic interventions were followed by progressive rehabilitation programs. Spasticity was assessed with modified Ashworth scale (mAS). In pre-/ and post orthopedic surgery, all patients were assessed using an adaptation for adults of the Gross Motor Function Classification Scale, Expanded and Revised (GMFCS – E&R).
Results Twelve patients had knee joint stiffness and chronic flexion contracture: 77% were severely limited in their walking ability, depending on wheelchair (GMFCS – E&R level IV), respectively 23% were bedridden, non-ambulate and totally dependent in all aspects of care (GMFCS – E&R level V).
Knee orthopedic serial interventions were followed by iterative, individualized rehabilitation treatments, and 50% subjects have regain their capacity to walk independently (GMFCS – E&R level II), respectively 50% succeeded to walked with assistive devices (GMFCS – E&R level III).
Discussion Both neuro-muscular system deficits and joint disorders can produce locomotor system abnormalities, joint complications and limb dysfunctional problems. These disturbances represent targets and therapeutic objectives for rehabilitation. Chronic knee flexion contracture, stiff elbows and/or hips, periarticular neurogenic heterotopic ossification: all represents major challenges in the complex management of patients with sequelae after CNS severe traumatic events.
Posterior capsulotomy addressed to a stiffed, distorted knee joint, corrects the limb axis and expands the range of motion (through the angle gained by the eliminated flexion contracture), and sometimes restores the patient's ability to walk. Serial orthopedic interventions, followed by sustained postoperative rehabilitation, had a decisive influence on obtaining good functional results.
Conclusions Comprehensive, multiprofessional approach and collaboration between neurorehabilitation and orthopedic teams are essential for the therapeutic management of patients with severe contractures post neuraxial lesions.
Proper evaluation and goal setting are mandatory for rehabilitative management, pre-/ and post orthopedic corrective surgery. Harmonized timing for iterative interventions, followed by postoperative structured, sustained (often for life-time) rehabilitation are essential for obtaining functional results. Adequate prophylaxis of complications represents a main therapeutic objective, as well.
Key words: traumatic brain injury (TBI), spinal cord injury (SCI), vegetative status, spasticity, contracture, capsulotomy, orthopaedic surgery, neurorehabilitation
Unusual localizations of heterotopic ossification in traumatic brain injury