The Effects of Exercise and Activity-Based Physical Therapy on Bone after Spinal Cord Injury

Spinal cord injury (SCI) produces paralysis and a unique form of neurogenic disuse osteoporosis that dramatically increases fracture risk at the distal femur and proximal tibia. This bone loss is driven by heightened bone resorption and near-absent bone formation during the acute post-SCI recovery phase and by a more traditional high-turnover osteopenia that emerges more chronically, which is likely influenced by the continual neural impairment and musculoskeletal unloading. These observations have stimulated interest in specialized exercise or activity-based physical therapy (ABPT) modalities (e.g., neuromuscular or functional electrical stimulation cycling, rowing, or resistance training, as well as other standing, walking, or partial weight-bearing interventions) that reload the paralyzed limbs and promote muscle recovery and use-dependent neuroplasticity. However, only sparse and relatively inconsistent evidence supports the ability of these physical rehabilitation regimens to influence bone metabolism or to increase bone mineral density (BMD) at the most fracture-prone sites in persons with severe SCI. This review discusses the pathophysiology and cellular/molecular mechanisms that influence bone loss after SCI, describes studies evaluating bone turnover and BMD responses to ABPTs during acute versus chronic SCI, identifies factors that may impact the bone responses to ABPT, and provides recommendations to optimize ABPTs for bone recovery.

Double-Level Osteotomy in Severe Varus Malalignment to Optimize Knee Joint Restoration

Background: Lower extremity alignment-correcting procedures for unicompartmental osteoarthritis are experiencing a rapid rise. Medial open-wedge high tibial osteotomy (MOW-HTO) thereby represents the most common technique among osteotomies but is limited in cases of severe malalignment. Some cases make a double-level osteotomy necessary. Indications: If planning of malalignment correction using a MOW-HTO results in a mechanical medial proximal tibial angle (mMPTA) of more than 93° (causing an oblique joint line), double-level osteotomy is indicated to avoid nonphysiological knee kinematics. Technique Description: After clinical examination and detailed analysis of malalignment (full-weight-bearing long-leg radiograph: hip-knee-angle [HKA], mMPTA, mechanical lateral distal femoral angle [mLDFA], joint line convergence angle [JLCA]), as well as individualized planning of the correction, the surgical procedure starts with an arthroscopy to evaluate the cartilage conditions and eventually treat intraarticular pathologies. Then, the femoral supracondylar correction is performed (closed wedge, biplanar osteotomy [ to increase bony healing]) according to the presurgical planning by resecting the osteotomy wedge with the measured length. K-wires are placed to check the correction. An angle-stable plate is used for osteosynthesis. The wedge taken out will be used as bone stock for the MOW-HTO afterward. The biplanar open-wedge tibial osteotomy is then performed subsequently using a medial tibial approach and an angle-stable plate. Opening of the osteotomy is then performed and double checked with intraoperative fluoroscopy using an alignment rod. Postoperative partial weight bearing for 6 weeks is recommended. Results: In recent literature, only few publications report on results of double-level osteotomies. Babis et al reports that it is a valuable procedure for patients with large varus deformity. Nakayama et al noted a significant improvement in patient-registered clinical outcomes in early postoperative evaluation of 20 patients. Schröter et al reports on 37 knees and findings include good clinical results, despite progressive osteoarthritis. Discussion/Conclusion: In cases of severe malalignment, adequate axis correction may require a double-level osteotomy. Exact preoperative planning is essential. Results reported in recent publications are promising. By splitting 1 large correction into 2 smaller ones, complications like hinge fracture and delayed bone healing are lowered.

The acute effects of vibratory stimuli during exercise on the sensorimotor control of the shoulder complex: A pilot study

BACKGROUND: Functional stability of the shoulder requires a balance of active forces, passive forces, and control subsystems of the joint complex. Although whole-body vibration enhances shoulder muscle function and proprioception, the impact of vibration on the sensorimotor control of the shoulder joint remains unclear. OBJECTIVE: To investigate the acute effect of vibratory stimuli on the sensorimotor control of the shoulder joint. METHODS: Fifteen male participants (age, 22.7 ± 2.3 years) were included and performed the exercise in a modified push-up position with partial weight-bearing on a vibration platform with and without vibratory stimuli. The vibration protocol included six sets lasting for 30 s each with a 30-s rest between sets. The main outcome measures included the upper limb static stability test, Upper Quarter Y Balance Test (UQYBT), and electromyography data of the upper limb. RESULTS: Vibratory stimuli resulted in an increased UQYBT score (all directions; P< 0.01) and infraspinatus, serratus anterior, and lower trapezius muscle activity (P< 0.05) between pre- and post-exercise versus the control condition. Stabilometric parameters showed no significant interaction between condition and time. CONCLUSIONS: Vibratory stimuli could maximize training benefits while limiting injury risk for athletes. Our findings could guide the development of rehabilitation programs for patients with shoulder instability.

Lateral Plantar Arch Reconstruction Using Vascularized Fibula Osteocutaneous Flap

A Sixteen-year-old male had a road traffic accident resulting in crush and loss of lateral two metatarsals of the left foot. The Lateral plantar arch was reconstructed with a vascularized fibula osteocutaneous flap. Flap survived and partial weight-bearing was started by 3 months and full weight-bearing was started 6-months post-surgery. At a 16-month follow-up patient had a normal gait and integrity of the lateral plantar arch was maintained. Vascularized fibula osteocutaneous flap is an excellent option for one-stage reconstruction of the lateral arch of the foot and gives satisfactory results in terms of functions of foot and in avoiding long-term morbidity.

A prospective study of retrograde nailing for distal third femoral shaft fractures

<p><strong>Background: </strong>To evaluate the postoperative knee range of motion and results of unreamed retrograde nailing for distal third femoral shaft fractures.</p><p><strong>Methods: </strong>Between June 2019 and June 2021 inclusive, a consecutive series of 20 patients who underwent retrograde nailing were prospectively evaluated. Outcome measures were union time, initiation of weight bearing, deformity and shortening, functional length of the nail, knee function assessed using a modified knee society knee score. Correlations between union time and other variables were also studied.</p><p><strong>Results: </strong>In these patients 18 (90%) of the 20 fractures achieved union, of which 4 underwent dynamisation; the mean union time for the other 18 fractures was 3.1 months. Angular malalignment was present in 2 patients and shortening in 3 others. There was negligible correlation between union time and variables of nail-canal diameter mismatch, functional length of nail, fracture geometry, or initiation of partial weight bearing ambulation. Knee flexion of more than 100 degrees was achieved in 19 patients. 14 patients had anterior knee pain and 7 had instability in early phases of ambulation. By the end of one year, excellent or good scores for pain and function were recorded in 95% and 86% respectively of the 20 patients.</p><p><strong>Conclusions: </strong>In view of such favourable union rates and no significant deterioration in overall knee joint function, at best retrograde nailing is a reliable alternative in the management of selected complicated fractures of the distal femoral shaft.</p>

Outcome of Intramedullary Interlocking Nailing in the Management of Gustillo-I Diaphyseal Fracture of Tibia

Objective: To evaluate the outcome of intramedullary interlocking nailing in the management of Gustillo-I diaphyseal fracture of tibia. Study Design: This is an observational study. Setting: Study carried out at Orthopaedic Surgery department, Liaquat University of Medical and Health Sciences Jamshoro, form March 2018 to February 2021. Materials & Methods: 72 consecutive patients of Gustillo Type-I diaphyseal fracture of tibia. All patients age between 18-60 years with traumatic fracture like Gustillo Type-I diaphyseal fracture of tibia were included in this study. Patients reported chest, abdominal and head trauma with neurovascular deficit were excluded. Patients were prepared for surgery after relevant investigation and radiographs. Results: Out of 72 patients included in this study 11.11% were female (N=8) and 88.88% male (N=64); with mean age was 38.26±8.20 years (Range 18 to 60 years). Road traffic accident was common cause of tibia fracture (Gustillo Type-I). Postoperative mean union time of tibial fractures were 9.9±3. 2 week.Postoperatively started partial weight bearing associated with help of two axillary crutches. The patients walking with partial weight bearing allowed at 4.1±1.12 weeks. While patients walking with full weight bearing allowed at 10.8±2.4 weeks. Postoperatively 11(15.27%) patients were complaining of pain. Wound infection observed in 7(9.72%) cases. Clinically excellent results were found in 24(33.33%) patients, while good results remained in 30(41.66%) patients and fairs in 18(25%) patients. Conclusion: We conclude that interlocking intra-medullary nailing may be considered as a suitable option for treatment of Gustilo-I diaphyseal fracture of tibia.

Malunited and malrotated Salter-Harris type I fracture of distal femur managed with circular ring external Ilizarov fixator

A 9-year-old girl presented with malunited Salter-Harris type I fracture of distal femur treated by bone-setter (unreliable-practitioner). Assessment revealed 3 cm limb-length-discrepancy and affected leg was unable to bear weight, knee was stiff with no active-range of motion; radiographs showed displaced sagittally malunited femoral condyle with 163° posterior distal femoral angle (PDFA). Correction planned with circular-ring-external Ilizarov fixator using distraction-osteogenesis through supracondylar osteotomy and gradual anterior opening. Partial weight bearing allowed from first postoperative day on walker. Eight weeks follow-up showed restored anatomical position of femoral condyle and PDFA. During anterior-distraction and angulation correction, tibia subluxated posteriorly, for that assembly extended to tibia which gradually translated tibia anteriorly and reduced knee. Twenty weeks after removal of assembly patient was advised knee-ankle-foot-orthosis. At 40 weeks of frame removal, patient was walking without support and pain. Managing such rare injuries with distraction-osteogenesis technique allows gradual correction and monitoring, till desirable degree of correction is achieved.

Novel Insole Material for Weight-Bearing Monitoring Medical Device to Be Used in Fractured Bone Clinic

Partial Weight-Bearing (PWB) regime is a part of a recreation process for patients with lower limb fractures/strains/sprains. In order to avoid a frequent foot overloading and achieve better patient compliance with requirement of PWB, the application of Weight-Bearing Monitoring System (WBMS) is highly attractive. However, it is challenging to find an affordable material for protective insole cover that is also a good shock-absorber. In this regard, a new formulation for protective covering material that preserves and isolates the sensors of WBMS device is suggested in this thesis. Twenty one samples of renewably sourced Polyurethane Foam (PUF) composed of poly (trimethylene ether) glycol (PO3G) and unmodified castor oil (CO) were synthesized and evaluated according to predetermined criteria. Response surface methodology of Box – Behnken design was applied to study the effect of the following parameters (polyols ratio, isocyanate index (II), and blowing agent ratio) on the properties (hardness, density) of PUFs. Results showed that CO/PO3G/TDI PUFs with hardness Shore A 17-22 and density of 0.19-0.25 g/cm3 demonstrate the required characteristics and can potentially be used as a durable and functional insole material. Phase separation studies have found the presence of well-segregated structure in PUFs having polyols ratio CO:PO3G 1:3 and low II, which further explains their extraordinary elastic properties (400% elongation). Analysis of cushioning performance of PUF signified that 5 samples have Cushioning Energy (CE) higher than 70 N·mm and Cushioning Factor (CF) in the range of 4-8, hence are recommended for application in WBMS due to superior weight-bearing and pressure-distributing properties. Moreover, the developed formulation undergoes anaerobic soil bacterial degradation and can be categorized as “green” bio-based material.

Novel Insole Material for Weight-Bearing Monitoring Medical Device to Be Used in Fractured Bone Clinic

Partial Weight-Bearing (PWB) regime is a part of a recreation process for patients with lower limb fractures/strains/sprains. In order to avoid a frequent foot overloading and achieve better patient compliance with requirement of PWB, the application of Weight-Bearing Monitoring System (WBMS) is highly attractive. However, it is challenging to find an affordable material for protective insole cover that is also a good shock-absorber. In this regard, a new formulation for protective covering material that preserves and isolates the sensors of WBMS device is suggested in this thesis. Twenty one samples of renewably sourced Polyurethane Foam (PUF) composed of poly (trimethylene ether) glycol (PO3G) and unmodified castor oil (CO) were synthesized and evaluated according to predetermined criteria. Response surface methodology of Box – Behnken design was applied to study the effect of the following parameters (polyols ratio, isocyanate index (II), and blowing agent ratio) on the properties (hardness, density) of PUFs. Results showed that CO/PO3G/TDI PUFs with hardness Shore A 17-22 and density of 0.19-0.25 g/cm3 demonstrate the required characteristics and can potentially be used as a durable and functional insole material. Phase separation studies have found the presence of well-segregated structure in PUFs having polyols ratio CO:PO3G 1:3 and low II, which further explains their extraordinary elastic properties (400% elongation). Analysis of cushioning performance of PUF signified that 5 samples have Cushioning Energy (CE) higher than 70 N·mm and Cushioning Factor (CF) in the range of 4-8, hence are recommended for application in WBMS due to superior weight-bearing and pressure-distributing properties. Moreover, the developed formulation undergoes anaerobic soil bacterial degradation and can be categorized as “green” bio-based material.