Functional Electrical Stimulation and Arm Supported Sit-To-Stand Transfer After Paraplegia: A Study of Kinetic Parameters

The sit-to-stand transfer of paraplegic patients using functional electrical stimulation (FES) of the knee extensors and arm support was analyzed in the study. In a group of 8 completely paralyzed subjects who were trained FES users, kinematic and dynamic parameters were recorded during standing up trials. A contactless optical system was used to assess the human body motion. The forces acting on the human body were measured by multi-axis force transducers. On the basis of recursive Newton-Euler inverse dynamic analysis, the forces and torques acting on the body joints were calculated. The joint moments in the lower and upper extremities during the sit-to stand task are presented in this paper. The influences of the patient's strength, FES training duration, and rising strategy on the joint loading are discussed.     

Retrograde Intramedullary Nailing for Distal Femur Fracture with Osteoporosis

Background

The incidence of distal femur fracture in the elderly has been increasing recently, and commonly occurs with osteoporosis. Retrograde intramedullary nailing has been considered a good surgical option for distal femur fracture. The purpose of the present study was to present our surgical results with retrograde intramedullary nailing for distal femur fractures with osteoporosis.

Methods

Thirteen patients diagnosed with extra-articular distal femur fracture and osteoporosis and managed with retrograde intramedullary nailing were retrospectively reviewed. Cement augmentation was used in four patients, shape memory alloy was used in eight patients and both were used in one patient. All patients were followed up for more than 2 years. Radiologic alignments were scored and Tegner and the Lysholm activity score was used for a functional assessment.

Results

The average time to clinical union was 13 weeks (range, 10 to 15 weeks). In 12 of our cases, the total alignment scores were excellent. At the last follow-up, the mean range of motion was 116° (range, 110° to 125°). The average functional score at postoperative 1 year was 2.6 (range, 1 to 5).

Conclusions

Retrograde intramedullary nailing is a good surgical option for distal femur fracture with osteoporosis. Cement augmentation and shape memory alloy can also be used for added mechanical stability. This surgical technique is very useful for distal femur fracture with osteoporosis as it promotes fracture healing and early rehabilitation.     

Paraplegia: Prolonged Standing Using Closed-Loop Functional Electrical Stimulation and Andrews Ankle-Foot Orthosis

One T10 paraplegic male (CS) implanted in 1991 with a Nucleus FES-22 stimulator has been able to achieve closed-loop standing for 1 h. The knee angles are monitored by electrogoniometers, resulting in the quadriceps stimulation time being less than 10%. Stance stability is achieved by the Andrews anterior ankle-foot orthosis (AFO). The use of accelerometers for trunk inclination and vertical acceleration during controlled stand-to-sit, diminishes slamming onto the seat. CS does one-handed tasks with objects of 2.2 kg. In another T10 paraplegic male (FR), surface stimulation was applied over 1.5 years to both femoral nerves at the groin for conditioning and prolonged standing. With quadricep conditioning, 55 Nm at 45 degrees of knee flexion is produced. With the AFO and knee monitoring, FR can stand uninterrupted for up to 70 min and perform one-handed tasks. In August 1998, he was implanted with the multifunctional Praxis FES 24-A stimulator for restoration of limb movements, bladder and bowel function, and pressure sore prevention.     

Mortality After Distal Femur Fractures in Elderly Patients

Background  

Hip fractures in the elderly are associated with high 1-year mortality rates, but whether patients with other lower extremity fractures are exposed to a similar mortality risk is not clear.     

Home-Based Functional Electrical Stimulation Cycling Enhances Quality of Life in Individuals with Spinal Cord Injury

Background:

With advances in medicine and increased survival rates, the focus of health care after spinal cord injury (SCI) has evolved from extending life to increasing independence and quality of life (QOL). Because enhancing QOL is an ultimate goal of the rehabilitation process, research involving the improvement of QOL is of great importance.

Objective:

The purpose of this study was to determine the effects of a home-based functional electrical stimulation lower extremity cycling (FES-LEC) program on the QOL of persons with SCI.

Design:

Eleven veterans with posttraumatic C4-T11 AIS A-C SCI participated in 8 weeks of 3 times weekly home-based FES-LEC. QOL was assessed using the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire. Tests were completed by all participants prior to and after the 8-week FES-LEC program.

Results:

There were significant increases in the physical and environmental domain QOL scores. There were nominal nonsignificant increases in the psychological and social domain QOL scores.

Conclusions:

The results of this study provide evidence that home-based FES-LEC 3 times per week for 8 weeks has the potential to result in QOL improvements.Key words: cycling, electrical stimulation quality of life, spinal cord injuryWith medical advances over the past century, there has been a dramatic increase in life-span of those with spinal cord injury (SCI).¹ This has changed the focus of health care after SCI from extending life to increasing independence and quality of life (QOL).² Chappell and Wirz³ state that enhancing QOL is the ultimate goal of rehabilitation, and the overall processes of optimizing physical function and independence comprise 2 of the many components of enhancing the QOL of persons with SCI. The US Surgeon General reports that physical activity is an important factor in promoting QOL. Persons with SCI have been shown to have decreased QOL after injury,^4–6 thus research measuring the effects of physical activity on the QOL of persons with SCI is necessary.The World Health Organization (WHO) defines QOL as the individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns. This concept takes into account the effect of physical health, psychological state, level of independence, social relationships, personal beliefs, and relationship to pertinent environmental features.⁷ One intervention that has been associated with the enhancement of QOL is physical activity.⁸ White and colleagues⁹ studied the effects of leisure time physical activities on community-dwelling older adults and found that physical activity and QOL were linked through selfefficacy, whereby physical activities that produce a positive experience and positive feedback are most likely to improve QOL. The study of the relationship between QOL and physical activity for persons with SCI is a more recent undertaking, thus there are relatively few studies that have targeted the psychological effects of regular physical activity in persons with SCI. Hicks et al² studied the effects of an upper body resistance training program using arm ergometry twice weekly for 9 months on the QOL of 34 individuals with SCI. Results showed positive QOL factors; the exercise group reported significantly less stress, fewer depression symptoms, and greater satisfaction with their physical functioning. The results also showed a nonsignificant increase in satisfaction in the selfperceived physical appearance of the exercise group relative to the control group. Fitzwater,¹⁰ a general medical practitioner and FES researcher, provided a personal view as a self-exerciser reporting the perception of improved body image and a preference for functional electrical stimulation lower extremity cycling (FES-LEC) over hand and arm activities. Our group has recently reported case reports utilizing a home-based FES-LEC program. Two older male adults with motor complete tetraplegia participated in FES-LEC 3 times per week for 9 weeks and 6 months, respectively. The results in both case reports showed improvements in perceived body image and self-esteem.^11,12 However, information concerning the effects of exercise, particularly FES-LEC on QOL of those with SCI, remains limited. The purpose of this study was to determine the effects of an Internetconnected home-based FES cycling program on the QOL (physical, psychological, social, and environmental health) of persons with SCI.     

L型钢板治疗股骨远端骨折26例分析

采用L型钢板治疗股骨远端骨折 2 6例 ,其中 2 3例随访 6个月～ 6年 ,15例疗效满意 ,优良率为 87%。L型钢板内固定是治疗股骨远端骨折较为有效的方法     

Functional Outcome of Total Knee Arthroplasty After Periprosthetic Distal Femoral Fracture

A prospective matched cohort study was performed to compare functional outcomes between 28 patients with periprosthetic femoral fractures and 28 with primary total knee arthroplasties (TKA). The mean follow-up was 6.7 years (range, 5–9). Radiographic osteopenia was a predisposing factor, but not notching, body mass index, or preinjury knee scores or motion. At last follow-up, the Knee Society scores, knee motion, Womac, and SF-12 were significantly lower in the fracture group, and were significantly decreased compared to the preinjury status. We found that periprosthetic distal femoral fracture after TKA worsens functional outcomes at the medium term, but arthroplasty complication and survival rates were similar in both groups.     

Disassembly of a Distal Femur Modular Prosthesis After Tumor Resection

We report and analyze the causes of a disassembly of a newly marketed distal femur modular prosthesis in a 20-year-old man with stage IIB osteosarcoma. The disassembly occurred after discharge from the hospital, after a minor trauma. Because of the unique displacement of the femoral component, sudden operative management was performed. Disassembly should be considered as a potential complication when choosing a modular prosthesis despite improvements in the design of some recent devices. In cases with a substantial amount of functional muscle excised at the time of tumor resection, adequate postoperative rehabilitation is recommended.     

Experiencing Functional Electrical Stimulation Roots on Education,and Clinical Developments in Paraplegia and Tetraplegia With Technological Innovation

Cybernetics‐based concepts can allow for complete independence for paralyzed individuals, including sensory motor recovery. Spinal cord injuries are responsible for a huge stress on health and a financial burden to society. This article focuses on novel procedures such as functional diagnosis for paraplegics and tetraplegics, cybertherapies toward lessening comorbidities such as cardiovascular diseases, osteoporosis, etc., and the production of new technology for upper and lower limb control. Functional electrical stimulation reflects a unique opportunity for bipedal gait to be achieved by paraplegics and tetraplegics. Education and training of undergraduates and postgraduates in engineering and life sciences have also been a major aim of this work.     

Dual-Plating in Distal Femur Fracture: A Systematic Review and Limited Meta-analysis

IntroductionAlthough lateral locking plate has shown promising results in distal femur fracture, there are high rates of varus collapse and implant failure in comminuted metaphyseal and articular fractures. This systematic review evaluates the functional outcomes and complications of dual plating in the distal femur fracture.Materials and methodsManual and electronic search of databases (PubMed, Medline Embase and Cochrane Central Register of Controlled Trials) was performed to retrieve studies on dual plate fixation in the distal femur fracture. Of the retrieved 925 articles, 12 were included after screening.ResultsThere were one randomized-controlled, four prospective and seven retrospective studies. A total of 287 patients with 292 knees were evaluated (dual plating 213, single plating 76, lost to follow-up 3). The nonunion and delayed union rates following dual plate fixations were up to 12.5% and 33.3%, respectively. The mean healing time ranged from 11 weeks to 18 months. Good to excellent outcome was observed in 55–75% patients. There was no difference between the single plate and dual plate fixation with regards to the functional outcomes (VAS score, Neer Score and Kolmert''s standard) and complications. Pooled analysis of the studies revealed a longer surgical duration (MD − 16.84, 95% CI − 25.34, − 8.35, p = 0.0001) and faster healing (MD 5.43, 95% CI 2.60, 8.26, p = 0.0002) in the double plate fixation group, but there was no difference in nonunion rate (9.2% vs. 0%, OR 4.95, p = 0.13) and blood loss (MD − 9.86, 95% CI − 44.97, 25.26, p = 0.58).ConclusionDual plating leads to a satisfactory union in the comminuted metaphyseal and articular fractures of the distal femur. There is no difference between the single plate and dual plate with regards to nonunion rate, blood loss, functional outcomes and complications. However, dual fixation leads to faster fracture healing at the cost of a longer surgical duration.     

股骨远端解剖钢板的设计与临床应用

目的　分析股骨远端解剖钢板的应用效果。方法　采用自行设计的股骨远端半环式解剖钢板治疗股骨远端各类型骨折38例。结果　 38例中 35例获 6～ 36个月的有效随访 ,30例骨折对位良好 ,钢板固定确实 ,膝关节伸屈功能≥ 90°,达到优良标准 ;3例骨折愈合 ,但关节仅有 1 5°～ 2 0°伸屈范围 ,经二次粘连松解手术后达到≥ 70°评为中 ;2例为差 ,一例骨不连作二次植骨愈合 ,一例关节强直作了人工膝关节置换。结论　以股骨远端为模板所设制的解剖钢板 ,具有良好的生物力学分布 ,克服了现有钢板偏心型固定所带来的缺点 ;其良好的复位 ,确实内固定效果 ,值得临床进一步推广使用     

经皮DCS微创固定治疗股骨远端严重粉碎性骨折

目的探讨应用经皮动力髁螺钉（dynamic condylar screw，DCS）微创固定技术治疗股骨远端严重粉碎性骨折的临床价值。方法2005年5月至2007年6月，采用经皮DCS微创固定技术治疗33例股骨髁间和／或股骨髁上的严重粉碎性骨折患者，术后早期进行功能锻炼。结果全部病例获得6～24个月随访，平均14个月。无感染、骨折不愈合、内固定松动、折断等并发症发生。结论应用经皮DCS微创固定技术治疗股骨远端严重粉碎性骨折，可以减少骨折部位血运破坏，降低不愈合率，同时固定坚强、有效，可以早期功能锻炼，值得临床推广应用。     

Seat Pressure Changes after Eight Weeks of Functional Electrical Stimulation Cycling: A Pilot Study

Background:

Pressure ulcers (PUs) are a common secondary condition associated with spinal cord injury (SCI). PUs can potentially interfere with activities of daily living, occupational duties, and rehabilitation programs, and in severe cases they may threaten life. Functional electrical stimulation (FES) cycling has been proposed as an activity that may decrease the risk of PUs through the promotion of increased blood flow and thickening of the gluteus maximus. The purpose of this pilot study was to measure the effects of home-based FES cycling on the average and maximal seat pressure of wheelchair-reliant individuals with SCI.

Method:

Eight male veterans with C5-T6 SCI participated in FES cycling 3 times per week. Cycling parameters were individualized depending on the comfort of the participants and the amount of current needed to perform the cycling activity. Pressure mapping was completed immediately before and after the 8 weeks of FES cycling with the measurement performed by a force sensitive application (FSA) 4 pressure mapping system.

Results:

The mean average seat pressure decreased by 3.69 ± 4.46 mm Hg (35.57 ± 11.99 to 31.88 ± 13.02), while the mean maximum seat pressure decreased by 14.56 ±18.45 mm Hg (112 ± 34.73 to 98.36 ± 25.89). Although neither measurement was statistically significant, there was a strong trend toward a reduction in average and maximal seat pressure (P = .052 and P = .061, respectively).

Conclusion:

The positive trend of decreased seat pressure in our study creates incentive for further investigation of the effects of electrical stimulation activities on seat pressure and the prevention of PUs.Key words: functional electrical stimulation cycling, pressure ulcer, seat pressure mappingPressure ulcers (PUs) are among the most common secondary conditions associated with spinal cord injury (SCI). According to the Model SCI System Statistical Center, approximately 15% of individuals with SCI will develop a PU within the first year of injury and approximately 27% over the first 25-year period post injury.¹ Additionally, 40% to 80% of those who develop a PU will have a recurrence.² PUs are also among the most troublesome as they potentially interfere with activities of daily living, occupational duties, and rehabilitation programs. In severe cases, PUs may be life threatening. Monetarily, they account for approximately 25% of the cost associated with SCI in the United States, totaling 1.6 billion dollars annually and 70,000 dollars per full-thickness PU.^3,4PUs are also commonly known as pressure sores, pressure wounds, or decubitus ulcers. Typically, PUs result from constant pressure on the skin in areas of the body where there is a boney prominence near the surface, such as ischial tuberosities, sacrum, greater trochanters, and calcaneus and olecranon processes.³Although there are many factors that play a role in the development of PUs, such as immobility, malnutrition, decreased blood circulation, and poor hygiene, the primary cause is the restriction of blood supply to soft tissue as a result of tissue compression between the external barrier to the skin (ie, bed, wheelchair seat, etc) and the internal bony prominence.⁵ When compression is sustained, the decrease in blood supply and oxygen to the local tissue results in tissue damage.^6,7 Sprigle and Sonenblum assert that even though the underlying causes of PU are quite complex, with multiple factors influencing tissue breakdown, PUs do not occur without forces or pressure being placed on soft tissue. Because the loading is the defining characteristic of PUs, it is reasonable to believe that the magnitude and duration of loading are key factors.⁸PUs are divided into 4 stages with increasing degree of severity. In stage 1, the skin is not broken but is red or discolored. The redness or change in color does not fade within 30 minutes after pressure is removed. In stage 2, the epidermis or topmost layer of the skin is broken, creating a shallow open sore. Drainage may or may not be present. For stage 3, the break in the skin extends through the dermis (second skin layer) into the subcutaneous and fat tissue. The wound is deeper than in stage 2. Finally, in stage 4, the breakdown extends into the muscle and can extend as far down as the bone. Usually lots of dead tissue and drainage are present.⁹Persons with SCI are particularly at risk due to their reliance on wheelchairs and their loss of sensation, which hinders their ability to feel pressure. The atrophied state of the gluteal muscles also decreases the amount of soft tissue and vascularity, which predisposes individuals with SCI to PUs.⁷Because of prolonged sitting due to paralysis, high pressure areas such as the ishium, greater trochanters, and the sacrum are especially at risk. Pressure relief techniques such as wheelchair pushups and directional trunk leaning in combination with mechanical pressure relief via tilt-in-space wheelchairs are designed to help decrease the risk of PUs. Likewise, a variety of seat cushions containing foam, gel, air, or a combination of these have been devised to maintain a healthy seat-buttocks interface. However, PUs remain a frequent problem for many of the 1.4 million wheelchair users in the United States.¹⁰ In fact, the incidence of PUs is reported to be as high as 38% in acute care, 23% in long-term care, and 17% in home environments.¹¹Garber and Rintala conducted a 3-year retrospective study on VA Medical Center out-patient veterans with SCI and found that 39% had been treated for PUs. Their study illustrates the magnitude of the problems of PUs associated with community-dwelling veterans with SCI.¹²Electrical stimulation has been used over the past 4 decades in an attempt to assist in the prevention of PUs. Strategies include altering the contour of the buttocks to enhance its surface interface with the seat and increasing the blood flow and soft tissue area of the gluteus maximus.^13–16In 1989, Levine and associates applied bilateral electrical stimulation to the guteal muscles and found simultaneous reduction of pressure under the ischial tuberosities with redistribution of pressure to lower risk areas of the seat.¹³ This demonstrated that relatively low levels of electrical stimulation could positively alter the seating interface. Later, Levine and colleagues studied the effectiveness of reducing seat pressure through the reconfiguration of the shape of the buttocks during low-level electrical stimulation of the gluteal muscles.¹⁷ Again the result was reduced seat pressure. The authors theorized that reduced seat pressure may assist in the prevention of PUs. Ferguson et al applied electrical stimulation to the quadriceps muscles and found that the greater the knee extension movement, the more significant the decreases in pressure at the ischial tuberosity.¹⁸ A decade later, Bogie and Triolo used implanted neuromuscular stimulation of the gluteal muscles to assist individuals with standing and transfer activities.¹⁴ In addition, they measured seat interface pressures and found that after 8 weeks of electrical stimulation, the ischial regions of the buttocks showed decreased pressure in a seated position. This alteration was matched with increases in tissue oxygen levels in the ischial area. These changes provided evidence that neuromuscular electrical stimulation can benefit tissue health.¹⁴Curtis and colleagues studied the use of intermittent electrical stimulation on the triceps surae of rats for 5 to 10 seconds every 10 minutes and found that it was effective in reducing deep muscle tissue damage caused by 28% and 38% body-weight pressures.¹⁶ Van Londen and associates completed a similar study on humans and found that the seat–buttocks interface pressure decreased whether the gluteal muscles were electrically stimulated simultaneously or alternately.¹⁹Functional electrical stimulation (FES) cycling has been proposed as an activity that may decrease the risk of PUs through the promotion of increased blood flow and thickening of the gluteus maximus.²⁰ Petrofsky et al compared the incidence of PUs in persons who performed FES cycling over a 2-year period with a non–FES cycling control group and found that the FES cycling group developed 90% fewer PUs.²¹ Nevertheless, research is lacking concerning the effects of FES cycling on seat pressure and its association with PUs. The purpose of this pilot study was to measure the effects of home-based FES cycling on the average and maximal seat pressure of wheelchair-reliant individuals with SCI.     

股骨远端A型和C型骨折手术治疗方法的研究

目的 探讨研究股骨远端A型和C型骨折手术治疗的方法,合理选用内固定,提高手术疗效.方法 2000年1月～2006年6月手术治疗58例A型或C型股骨远端骨折.结果 患者随访时间9～36个月,均获得骨性愈合,无内固定物断裂、感染等并发症发生.按HSS评分标准:优23例,良28例,可6例,差1例.结论 手术治疗股骨远端A型和C型骨折可以取得满意的疗效,应根据股骨远端骨折的特点选择合适的内固定方式,手术时尽可能取得满意的复位和坚强的内固定,同时不能忽视早期患肢的康复训练.     

Functional Capacity Before and After Liver Transplantation

The maximal oxygen uptake (VO₂ max) is a standard tool for preoperative counseling of candidates for lung and heart transplantations, as well as an optional measurement to assess liver or renal transplant patients. Also, it provides an objective tool of the functional capacity of posttransplant patients. Exercise limitation and loss of aerobic capacity are common among patients with end-stage liver disease. The functional capacity of these subjects is decreased, as estimated by measuring the VO₂ max in a cardiopulmonary exercise test (CPET). After transplantation improvement is expected in physical capacity. We sought to describe the influence of orthotopic liver transplantation (OLT) on the physical fitness of the recipient at 3 and 12 months after transplantation. Since CPET is an objective test, it is an important tool for clinicians to evaluate patients' functional capacity before and after OLT.     

Intra-articular Fracture Pattern in Intercondylar Distal Femur Fractures: An Analysis of Frequency and Major Fracture Fragments

IntroductionThe treatment of intercondylar distal femur fractures requires anatomic reduction of intra-articular fragments and absolute fixation. Preoperative planning is necessary to understand fracture morphology. All fracture lines need to be recognized as the primary implant may not capture all articular fragments, mainly when coronal plane fractures are present. Oftentimes, independent interfragmentary compression screws are necessary. No recent studies have visually mapped out the distal femur articular fracture fragments necessary for absolute fixation. The objectives of this study are to determine the frequency of coronal plane fractures in intercondylar distal femur fractures and describe the pattern of intra-articular fracture fragments.Materials and MethodsThe hospital's trauma registry was queried for distal femur ORIF CPT codes logged in the past four years. A retrospective chart review was performed using the EMR and CT scans. Demographics and mechanisms of injury were analyzed. Fracture fragments were surveyed and drawn out by hand on a template for easy organization. Patients’ fractures were categorized into the following groups: fractures with no intra-articular coronal plane fractures, those with medial coronal fractures, those with lateral coronal fractures, or those with both medial and lateral coronal fractures. Major fracture fragments were identified.ResultsA total of 55 patients were included. 26 patients (47%) were found to have no intra-articular coronal plane fractures; 6 patients (11%) were found to have medial coronal plane fractures; 15 patients (27%) were found to have lateral coronal plane fractures, and 8 patients (15%) had medial and lateral coronal plane fractures. Collectively, intra-articular coronal plane fractures were identified in 29 patients (53%) with intercondylar distal femur fractures. Four major fracture fragments along with intercondylar and condylar comminution sites were identified.DiscussionDistal femur intra-articular coronal plane fractures can yield large anterior and posterior condylar fracture fragments of either the medial condyle, lateral condyle, or both condyles. Coronal plane fracture fragments must be identified to obtain absolute fixation. Our study found a higher coronal plane fracture line frequency (52.7%) than prior commonly cited studies. Surgeons must be on the lookout for anterior fracture fragments, posterior fracture fragments, and articular comminution when treating intercondylar femur fractures.     

Functional Electrical Stimulation in Paraplegic Spastic Patients

Abstract: We are reporting on the clinical and physiological effects of 8 months of functional electrical stimulation (FES) of the quadriceps femoris muscle on 10 paraplegic patients. Each patient had muscle biopsies, computed tomography (CT) muscle diameter measurements, and knee extension strength testing both before and after 8 months of FES training. Skin perfusion was documented through infrared telethermography and xenon clearance; muscle perfusion was recorded through thallium scintigraphy. After 8 months of FES training, the baseline skin perfusion showed an 86% increase; muscle perfusion was augmented by 87%. Muscle fiber diameters showed an average increase of 59% after 8 months of FES training. Muscles in patients with spastic paresis showed an increase in aerobic and anaerobic muscle enzymes up to the normal range of healthy humans. The increment in muscle area, as visible on CT scans of the quadriceps femoris muscle, was 30%. Using FES, we were able to improve metabolism and to induce positive trophic changes in our patients' lower extremities. In spastic paraplegics, rising and walking achieved through FES are much better training than FES ergometer training. Larger muscle masses are activated, and the heart rate is increased; therefore, the impact on cardiovascular fitness and metabolism is much greater. This effectively addresses and prevents the problems that result from inactivity in paraplegic patients.