Partial monopolar transfer of pectoralis major for elbow active flexion restoration in children with arthrogryposis

BACKGROUND: One of the main problems that limited or made the self-ability of patients with arthrogryposis impossible is the lack of active elbow flexion due to hypoplasia (or aplasia) of the forearm flexors and, especially the m. biceps brachii. AIM: To evaluate the possibility of active forearm flexion restoration in children with arthrogryposis by partial monopolar transposition of the pectoralis major muscle. MATERIALS AND METHODS: Elbow active flexion restoration by partial monopolar transposition of the pectoralis major muscle to biceps brachii was conducted in 34 children with arthrogryposis (39 upper limbs) from 2011 to 2020. The muscle autograft included a fragment of the fascia of the m. rectus abdominis. Clinical examinations of patients were performed before and after the operation. Statistical data processing was performed using the software packages Statistica 10 and SAS JMP 11. RESULTS: The follow-up results were estimated from 6 to 99 months (44.53 31.72) postoperative. The mean age of patients was 6.24 4.24 years. The active postoperative elbow motion was 0120 (71.94 33.40). The passive postoperative elbow motion did not change and was 90130 (104.12 12.40). Muscles strength after the operation was grade 25. Elbow extension was limited in 30 cases (76.9%) from 0 to 40 (21.70 12.27) without problem in the activities of daily living. Good results were determined in 15 cases (38.5%), satisfactory in 8 (20.5%), and poor in 16 (41%). CONCLUSIONS: This study revealed that our partial monopolar transfer of pectoralis major to biceps brachii technic restored sufficient forearm flexion and improved self-ability without forming severe elbow flexor contractures of more than half of the patients with arthrogryposis.

Arthroscopic management of elbow stiffness

The elbow is particularly prone to stiffness. Loss of elbow motion is very limiting, and can be the result of trauma, primary osteoarthritis, heterotopic ossification and other conditions. Several exposures have been described for open elbow contracture release. Although a few decades ago elbow arthroscopy was considered only for diagnosis and removal of loose bodies, contemporary arthroscopic techniques allow successful management of the majority of conditions leading to elbow stiffness. Careful patient evaluation, use of advanced imaging studies, and acquisition of appropriate surgical skills are essential for the successful arthroscopic management of the stiff elbow. This expert opinion reviews some fundamentals of elbow stiffness as well as principles for the evaluation and arthroscopic management of the stiff elbow.

Radial Head Lag: A Possible Biomechanical Mechanism for Osteochondritis Dissecans of the Capitellum in Baseball Pitchers

Background: Osteochondritis dissecans (OCD) of the capitellum is common in throwing athletes and is believed to result from repetitive overloading on the radiocapitellar (RC) joint, although the cause and mechanism remain unclear. The torsional forces (moments) generated by the triceps during elbow extension pull only on the ulna; therefore, the radial head moves passively across the capitellum and is effectively “dragged along” by the ulna. Any laxity in the proximal radioulnar joint could lead to asynchronous motion between the radius and ulna, resulting in the radial head lagging behind the coronoid and possibly malarticulating with the capitellum during such motion. Hypothesis: Radial head motion on the capitellum lags behind ulnohumeral joint motion during simulated throwing. Study Design: Controlled laboratory study. Methods: A total of 8 cadaveric elbows were tested under simulated throwing, including active extension of the elbow generated by pulling of the triceps under valgus stress, as well as during passive extension under valgus stress to serve as a reference. Ulnohumeral motion was tracked using a video camera. Radial head motion was tracked using an intra-articular, thin-film pressure sensor mounted on the capitellum, and the longitudinal movement of the center of force (COF) of the radial head was measured. Radial head motion was compared between passive and active motion for each 10° of elbow extension from 90° to 20°. Results: Elbow motion during simulated active extension reached an angular velocity of 366 deg/s. Radial head motion during simulated active extension significantly lagged compared with its motion during passive extension at every elbow extension angle examined between 70° and 20° ( P < .001). The maximal lag reached a mean of 4 mm (range, 2-7 mm). In other words, RC and ulnohumeral motion were asynchronous during simulated throwing. Conclusion: This study describes a novel phenomenon: motion of the radial head across the capitellum during rapid extension, such as in baseball pitching, lags behind that seen during passive elbow motion. According to a new proposed theory of OCD lesion development, this lag should result in RC incongruency and elevated shear forces on the capitellum due to edge loading. Clinical Relevance: We propose a new biomechanical explanation for OCD of the capitellum in baseball pitchers: radial head lag. Understanding this process is the first step in efforts to prevent this common injury.

Design and Experimental Characterization of L-CADEL v2, an Assistive Device for Elbow Motion

An experimental characterization is presented for an improved version of a wearable assistive device for elbow motion. The design is revised with respect to requirements for elbow motion assistance, looking at applications both in rehabilitation therapies and exercising of elderly people. A laboratory prototype is built with lightweight, portable, easy-to-use features that are verified with test results, whose discussion is also provided as a characterization of operating performance.

Effect of post-stroke spasticity on voluntary movement of the upper limb

Background Hemiparesis following stroke is often accompanied by spasticity. Spasticity is one factor among the multiple components of the upper motor neuron syndrome that contributes to movement impairment. However, the specific contribution of spasticity is difficult to isolate and quantify. We propose a new method of quantification and evaluation of the impact of spasticity on the quality of movement following stroke. Methods Spasticity was assessed using the Tonic Stretch Reflex Threshold (TSRT). TSRT was analyzed in relation to stochastic models of motion to quantify the deviation of the hemiparetic upper limb motion from the normal motion patterns during a reaching task. Specifically, we assessed the impact of spasticity in the elbow flexors on reaching motion patterns using two distinct measures of the ‘distance’ between pathological and normal movement, (a) the bidirectional Kullback–Liebler divergence (BKLD) and (b) Hellinger’s distance (HD). These measures differ in their sensitivity to different confounding variables. Motor impairment was assessed clinically by the Fugl-Meyer assessment scale for the upper extremity (FMA-UE). Forty-two first-event stroke patients in the subacute phase and 13 healthy controls of similar age participated in the study. Elbow motion was analyzed in the context of repeated reach-to-grasp movements towards four differently located targets. Log-BKLD and HD along with movement time, final elbow extension angle, mean elbow velocity, peak elbow velocity, and the number of velocity peaks of the elbow motion were computed. Results Upper limb kinematics in patients with lower FMA-UE scores (greater impairment) showed greater deviation from normality when the distance between impaired and normal elbow motion was analyzed either with the BKLD or HD measures. The severity of spasticity, reflected by the TSRT, was related to the distance between impaired and normal elbow motion analyzed with either distance measure. Mean elbow velocity differed between targets, however HD was not sensitive to target location. This may point at effects of spasticity on motion quality that go beyond effects on velocity. Conclusions The two methods for analyzing pathological movement post-stroke provide new options for studying the relationship between spasticity and movement quality under different spatiotemporal constraints.

Ultrasonographic Findings of the Ulnar Nerve Following Elbow Flexion in Patients with Cubital Tunnel Syndrome

Objective To evaluate the ultrasonographic findings obtained following various degrees of elbow flexion in patients with cubital tunnel syndrome (CuTS). Design Retrospective, cross-sectional study. Setting General teaching hospital, rehabilitation unit. Subjects Electrophysiological and ultrasonographic assessments were performed on 11 elbows of healthy controls and 21 elbows of 17 patients with CuTS. Methods Dynamic movement of the ulnar nerve during elbow motion was measured. To measure ulnar nerve dynamic movement during elbow motion, the distance from the medial epicondyle (ME) to the nearest surface of the ulnar nerve toward the ME was measured at the cubital tunnel inlet at elbow extension (0°), elbow flexion to 60°, and elbow flexion to 90°. Results The distance between the ME and ulnar nerve was lower in CuTS patients than in healthy patients at all elbow flexion angles. This difference was statistically significant at 0° and 60° elbow flexion (P &lt; 0.05). When calculating the cutoff value, the distance between the ME and ulnar nerve at full elbow extension for CuTS diagnosis was 0.53 cm (sensitivity = 71.4%, specificity = 90.7%). The distance ratio between the ME and ulnar nerve for diagnosis of ulnar neuropathy at the elbow was 24.4% (sensitivity = 76.2%, specificity = 100%). Conclusion Measurement of the distance between the ME and ulnar nerve in full elbow extension may facilitate the diagnosis of patients with CuTS. These findings may be important for CuTS diagnosis, as they were also observed in patients with mild-stage CuTS.

TO EVALUATE THE OUTCOME OF PLATE FIXATION FOR DISPLACED OLECRANON FRACTURES: AN ANALYTICAL STUDY.

Objectives: To evaluate the outcome of plate fixation for displaced olecranon fractures Materials and Methods: the present retrospective study was conducted in the Department of Orthopedics Jawaharlal Nehru Medical College, Bhagalpur from jan 2018 to October 2018. Total 25 patients who underwent plate fixation of displaced olecranon fractures were reviewed by two surgeons were independently. Results: mean arc of elbow motion 106.20 with range of motion from 10.20-116.70 and excellent clinical outcome was reported among 76% cases as per Broberg and Morrey scale. 22 patients achieved fracture union during 6 months follow up period. Conclusion: Plate fixation is an effective treatment option for displaced olecranon fractures with a good functional outcome and a low incidence of complications. Keywords: Olecranon, Fracture, Plate fixation, Ulna