Voluntary ambulation using voluntary upper limb muscle activity and Hybrid Assistive Limb® (HAL®) in a patient with complete paraplegia due to chronic spinal cord injury: A case report

Context: We sought to describe our experience with the Hybrid Assistive Limb® (HAL®) for active knee extension and voluntary ambulation with remaining muscle activity in a patient with complete paraplegia after spinal cord injury.

Findings: A 30-year-old man with complete paraplegia used the HAL® for 1 month (10 sessions) using his remaining muscle activity, including hip flexor and upper limb activity. Electromyography was used to evaluate muscle activity of the gluteus maximus, tensor fascia lata, quadriceps femoris, and hamstring muscles in synchronization with the Vicon motion capture system. A HAL® session included a knee extension session with the hip flexor and voluntary gait with upper limb activity. After using the HAL® for one month, the patient’s manual muscle hip flexor scores improved from 1/5 to 2/5 for the right and from 2/5 to 3/5 for the left knee, and from 0/5 to 1/5 for the extension of both knees.

Conclusion/clinical relevance: Knee extension sessions with HAL®, and hip flexor and upper-limb-triggered HAL® ambulation seem a safe and feasible option in a patient with complete paraplegia due to spinal cord injury.     

Intermittent Internal Fixation With a Locking Plate to Preserve Epiphyseal Growth Function During Limb-Salvage Surgery in a Child With Osteosarcoma of the Distal Femur: A Case Report

Limb shortening is a problem associated with surgery for osteosarcoma of the lower extremity in adolescents, as the tumors frequently occur near the epiphysis. Herein we report the use of a less invasive stabilization system (LISS) and an intermittent fixation method to preserve the growth function of epiphysis in an 11-year-old patient with an osteosarcoma of the distal femur.The 11-year-old male presented with left knee enlargement and pain for 2 weeks, and magnetic resonance imaging (MRI) and biopsy were consistent with osteosarcoma of the left distal femur. After preoperative chemotherapy, en bloc tumor resection was performed with margins based on MRI findings preserving the epiphyseal growth plate, the tumor cavity was filled with inactivated bone and bone cement, and a LISS was used to stabilize the femur. Aggressive postoperative chemotherapy was given. Approximately 105 weeks after surgery radiography showed that the distal end of the plate had moved superior to the epiphysis along with bone growth. Locking screws were placed in the distal part of the LISS plate to stabilize the re-implanted bone, and external fixation was not needed.The patient was able to walk with the crutches 1 week postoperatively, and bear weight on the extremity 6 weeks postoperatively. At 6 years after surgery, the patient''s height had increased 52 cm, shortening of the affected limb was only 1 cm, and the circumference of the affected limb was 2 cm smaller than that of the contralateral limb. There was no significant discomfort in the affected limb, and there was no gait abnormality. The patient could jump and run, and could participate in sports including basketball and badminton to the same degree as his peers.In summary, the novel method of bone reconstruction and fixation provided good results in a child with an osteosarcoma of the distal femur. This fixation method preserves the osteogenic function of the epiphysis and restored bone integrity simultaneously, and provides good functional recovery.     

Clinical outcomes of bypass-first versus endovascular-first strategy in patients with chronic limb-threatening ischemia due to infrageniculate arterial disease

Background

Chronic limb-threatening ischemia (CLTI), defined as ischemic rest pain or tissue loss secondary to arterial insufficiency, is caused by multilevel arterial disease with frequent, severe infrageniculate disease. The rise in CLTI is in part the result of increasing worldwide prevalence of diabetes, renal insufficiency, and advanced aging of the population. The aim of this study was to compare a bypass-first with an endovascular-first revascularization strategy in patients with CLTI due to infrageniculate arterial disease.

上肢骨肿瘤切除后的自体骨移植重建

目的探讨应用自体骨移植对上肢骨肿瘤切除后的骨缺损修复重建的效果。方法1998年8月～2004年3月，收治上肢骨肿瘤切除后的骨缺损16例。男8例，女8例。年龄7～45岁。经病理确诊，肱骨近端尤文肉瘤和骨肉瘤各1例；肱骨远端尤文肉瘤2例；桡骨远端骨巨细胞瘤8例，高分化软骨肉瘤2例，恶性纤维组织细胞瘤和骨肉瘤各1例。2例肱骨近端肿瘤行自体锁骨代肱骨；2例肱骨远端肿瘤行自体腓骨代肱骨；12例桡骨远端肿瘤中，1例行自体髂骨移植，11例行自体腓骨代桡骨进行重建。采用MSTS系统进行术后功能评价。结果2例肱骨近端自体锁骨移植患者分别随访36个月和12个月，术后保持部分肩关节前屈和后伸功能，但外展功能丧失；MSTS评分分别为23分和22分。2例肱骨远端自体腓骨移植患者分别随访4个月和6个月，肘关节功能良好，移植骨连接处已经出现骨愈合；MSTS功能评分分别为24分和19分。12例桡骨远端自体骨移植患者中11例随访6～75个月，功能良好，无明显并发症；1例髂骨植骨的桡骨远端骨巨细胞瘤术后3个月移植骨完全愈合，至今随访75个月，肿瘤无复发。MSTS功能评分18~27分，平均22．6分。结论自体骨移植在上肢骨肿瘤切除后骨缺损的重建，尤其是儿童的骨缺损重建中，是一种较好的方法。     

When should patients begin ambulating following lower limb split skin graft surgery? A systematic review

Pretibial lacerations and lower limb wounds are referred to plastic surgery teams for split skin graft surgery. Traditionally, these patients have been immobilised on bedrest following surgery. More recently, patients have commenced ambulation earlier to avoid medical complications and facilitate discharge. The objective of this literature review was to determine when such patients should begin walking. A literature search was undertaken using the electronic databases AMED, Cinahl, Embase, Medline (via Ovid), PEDro and Pubmed. Clinical trials using human subjects, written in English, were included. Seventeen (of 1137) papers met the inclusion criteria and were reviewed. The literature suggested that patients should begin walking immediately or at the earliest possible opportunity after lower limb skin graft surgery. Although the literature advocated early ambulation, the evidence base presented with a number of recurrent methodological limitations, including small sample sizes, lack of a control sample, and limited follow-up. Accordingly, further research employing large, well-designed, randomised controlled trials is recommended. It will then be possible to understand with greater certainty when patients should begin walking after lower extremity split skin graft surgery.     

偏瘫病人下肢功能康复阻碍因素初探

观察了10项因素对偏瘫病人下肢功能康复的影响,其结果表明:①下肢功能水平;②平衡功能障碍;③足下垂内翻;④髋关节屈曲外旋挛缩;⑤深感觉障碍;⑥疼痛等几项因素对偏瘫病人下肢功能康复有显著的影响。     

髋臼骨折合并同侧下肢骨折临床治疗分析

目的：探讨髋臼骨折合并同侧下肢骨折的创伤机制和治疗方法。方法：髋臼骨折并同侧下肢骨折14例,男9例,女5例;年龄18～65岁,平均35岁。髋臼骨折按Letournel分型,后壁伴后柱骨折11例,单纯后柱骨折3例,均行钢板内固定。伴同侧股骨转子间骨折3例,1例行起重机架外固定,2例行DHS固定;伴同侧股骨颈骨折3例,均行空心钉加压固定;伴同侧股骨干骨折6例,1例行钢板固定,余5例行带锁髓内钉固定;伴同侧胫骨平台骨折2例,行钢板内固定。结果：1例半年后死亡,余13例获得随访,随访时间18个月～5年,平均30个月。按照美国矫形外科研究院髋关节疗效评定标准,优9例,良3例,差1例。结论：髋臼骨折合并同侧下肢骨折受伤暴力大、机制复杂、合并创伤多、易漏诊,应早期明确诊断,合理内固定。     

The laterally extended medial hemisoleus flap for reconstruction of a tibial wound in the distal third of the leg

A soleus flap as a local reconstructive option for soft-tissue coverage of a tibial wound in the distal third of the leg has never been well recognized. In a 2-year period, seven patients underwent reconstruction of a less extensive tibial wound (4 × 3 to 10 × 4 cm) in the distal third of the leg after orthopedic trauma with the laterally extended medial hemisoleus flap. The flap was elevated with emphasis on the preservation of the most distal perforators from the posterior tibial vessels to the flap as possible while allowing adequate rotation of the flap to cover the exposed tibia and/or hardware and on the possible preservation of foot planter flexion by reconstruction of the proximal Achilles’ tendon. In this series, there was no total or partial flap loss. All patients healed their tibial wounds primarily with reliable soft-tissue coverage, evidenced fracture healing, and good cosmetic outcome during follow-up. Thus, the laterally extended medial hemisoleus flap described by the author can be a reliable option for soft-tissue coverage of a less extensive tibial wound in the distal third of the leg. It offers a more cost-effective approach for managing this unique problem and can be performed by most reconstructive surgeons without microsurgical expertise.     

Bilateral Ulnar Agenesis: Case Report and Review of the Literature

Bilateral ulnar agenesis is a rare abnormality. A total of 36 cases are analyzed: 35 of these are documented in the literature and 1 stillborn male is presented in this study. Most patients had one of the three conditions: Al-Awadi/Raas-Rothschild syndrome, syndrome of ulnar aplasia with split hand/split foot deformity, or the Brachmann—de Lange syndrome. Fifty percent of all cases with bilateral ulnar agenesis were associated with lower limb defects and these cases, for the most part, also belonged to the aforementioned syndromes. Nonskeletal, internal organ malformations were identified in 34% of all patients. Nine patients presented with isolated bilateral ulnar agenesis. The Al-Awadi/Raas-Rothschild syndrome and the split hand/split foot deformity are heritable disorders. There was no evidence for genetic etiology in most of the other cases. Bilateral ulnar agenesis in our fetus was part of the Brachmann—de Lange syndrome with associated cardiac defect, diaphragmatic hernia, and umbilical artery agenesis.     

Analysis thrombolysis with anticoagulation treatment for early stage of deep vein thrombosis in the lower extremities

Objective:To explore the effect of thrombolysis with anticoagulation treatment forearly stage of deep vein thrombosis of lower extremity.Methods:The clinical data of 10 patients at the early stage of deep vein thrombosis(DVT)in the lower extremuites treated by thrombolysis with anticoagulation and dispersion drugs were analyzed retrospectively.Results:The thrombolytic effect was significant.After treatment,the deep veins were recanalized without regurgitation in 75.3% of the patients.The total effective rate was 100%.Only three patients had hemorrhagic complication,but none of the patients died.Conclusion:Thrombolysis with anticoagulation treatment is an effective and safe method for DVT at the early stage.