Passive motion of the elbow joint.

A previously unreported method of measuring three-dimensional motion of joints, applied to two elbows obtained post mortem, showed that during flexion there is a continuous and linear change in the carrying angle, the forearm going into varus angulation as elbow flexion progresses. In addition, internal axial rotation of the forearm occurs near the beginning and external axial rotation, toward the end of flexion. With the elbow extended, the ulna shows little tendency to deviate laterally or to rotate axially during pronation and supination. The axis of rotation during elbow flexion lies approximately at the center of the trochlea.     

Resection of elbow ossification and continuous passive motion in postcomatose patients.

Heterotopic periarticular ossifications were surgically excised in 16 elbows of 14 traumatic brain injury patients an average of 18.9 months (range, 4-67 months) after the end of coma. In 11 elbows the ulnohumeral joint was ankylosed in a position that ranged from 0 degrees to 100 degrees of flexion (group 1); in 5 elbows the arc of flexion ranged from 10 degrees to 25 degrees (group 2). Full pronation and supination were present in 15 of the elbows; in 1 the radiocapitellar joint was fixed at 30 degrees of pronation by a partial ossification of the interosseous membrane. The arc of flexion attained after surgery averaged 115 degrees (range, 90 degrees to 145 degrees) in the group 1 elbows and 128 degrees (range, 115 degrees to 140 degrees) in the group 2 elbows. In an attempt to prevent postoperative loss of motion and recurrence of ossification, continuous passive motion was applied to the affected elbow for 6 weeks before starting a fully active rehabilitation program. All the patients were examined at regular intervals after the surgery. The follow-up period ranged from 12 to 60 months (average, 30.7 months). During the follow-up period, all the elbows showed improvement in range of motion and the arc of flexion averaged 95 degrees (range, 30 degrees to 135 degrees) in the group 1 elbows and 116 degrees (range, 80 degrees to 145 degrees) in the group 2 elbows. Patients with poor neuromuscular control lost part of their postoperative range of motion and partial recurrence was observed in 3 elbows. We believe that our improved results, compared with those obtained by previous investigators, may have been due to the prolonged application of continuous passive motion after surgery.     

肘关节镜微创治疗肘关节屈伸功能障碍

目的探讨肘关节镜微创治疗肘关节屈伸功能障碍的适应证、手术方法及术后康复锻炼。方法对自2008年11月~2011年8月收治的29例肘关节屈伸活动功能障碍均行肘关节镜下松解清理术,术后按统一标准化方案行康复功能训练,对比术前、术后肘关节屈伸活动度,采用Mayo肘关节功能评分进行比较。结果患者术后获随访8~16个月,平均11.3个月,21例肘关节屈伸活动功能均有很大程度的改善。术前平均主动伸直活动度为(38±24)°,屈曲活动度为(102±19)°。术后平均主动伸直活动度为(10±7)°,屈曲活动度为(118±15)°,术前、术后伸直活动度改善(27.8±10.4)°,术前、术后屈曲活动度增加(16.4±3.3)°,术前及术后屈、伸活动度差异有统计学意义(P<0.05)。采用Mayo肘关节功能评分进行比较,术前良8例,中15例,差6例;术后优8例,良14例,中5例,差2例。结论肘关节镜微创治疗肘关节屈伸功能障碍具有创伤小、康复快、是一种有效治疗肘关节屈伸功能障碍的方法。     

Functional anatomy of the elbow joint and three-dimensional quantitative motion analysis of the elbow joint

This work consists of two parts. Part One is a three-dimensional study of the passive motion of the elbow joint and revealed that the elbow joint was not a true hinge joint. Part Two is a three-dimensional quantitative motion analysis which was undertaken to compare shoulder and trunk motion in normal subjects with those with contracted elbows. This analysis revealed that shoulder rotation, shoulder abduction, trunk flexion and trunk rotation compensates for a contracted elbow.     

Physiology and therapeutic value of passive joint motion

Despite the long history of therapeutic experience with different types and amounts of passive joint motion, its effects and the principles of its use remain controversial. Through empiric success, a spectrum of passive motion has evolved for various clinical purposes, including joint diagnosis; correction of joint deformities; mobilization of stiff joints; stimulation of joint healing; neuromuscular re-education; and prevention of immobilization complications (e.g., contracture formation, connective tissue atrophy, relative healing inhibition, and associated stasis abnormalities). However, the potential abuses of passive motion (e.g., causing additional tissue trauma, mobilizing unprotected joints, and stretching the wrong joints or tissues) have created serious doubts as to the value of this therapy and raised important questions concerning the lack of proper definition (e.g., force, direction, speed, and duration) and the unknown margins of safety. Clinical and experimental evidence supports the probable effectiveness of passive joint motion on joint and tissue levels, but without a better quantitative understanding of the mechanisms of action, dose-responsiveness, specific tissue effects, and, most important, their controls. Thus, passive motion will continue to be used suboptimally with inconsistent results. When these clinical and research deficiencies are corrected, passive motion will attain its proper place as a powerful and reliable orthopedic tool.     

Carpal kinematics during simulated active and passive motion of the wrist

PURPOSE: The purpose of this study was to investigate the effect of experimental control mechanisms, simulated active (tendon-driven) and passive (externally assisted), on carpal motion. METHODS: Kinematics of the carpal bones in five fresh-frozen cadaver upper extremities were studied using an optical motion analysis system. The wrist extensors and flexors were dissected and loaded. For passive motion, the tendons were loaded to simulate muscle tone while the investigator passively moved the wrist using a pin placed in the third metacarpal. To simulate active, patient-driven motion, the tendons were attached directly to guide bars while the investigator used a puppeteer mechanism to move the wrist. RESULTS: There were no significant differences in carpal motion (flexion-extension motion or radial-ulnar deviation) when the wrist was moved in simulated active motion through the extensor and flexor tendons or in passive motion, with a constant force applied to the tendons. Kinematics for simulated active motion, in general, was more difficult to control and was less smooth than the kinematics for passive motion. CONCLUSIONS: Carpal bone kinematics (excluding the pisiform) in a healthy normal joint are similar in both simulated active (tendon-driven) and passive (externally assisted) wrist motion because the carpal bones are passively moved during wrist motion (there are no direct tendon-to-muscle attachments to the proximal carpal bones and minimal attachments to the distal carpal bones).     

Continuous passive motion following partial ankle joint arthroplasty

Retrospective preliminary report of 19 cases undergoing partial ankle joint arthroplasties with open surgical procedures were rehabilitated with continuous passive motion (CPM). Preoperative and post-operative ankle range of motion and subjective findings (pain, physical signs, activity, quality of motion) were evaluated. Results indicated significant increases to ankle joint range of motion with the use of continuous passive motion, decreased pain, increased activity, decreased edema, and improved quality of motion in the majority of patients undergoing ankle joint arthroplasty with continuous passive motion.     

肘关节牵伸成形术治疗外伤后屈肘挛缩畸形(附3例报告)

[目的]探讨肘关节牵伸成形术治疗外伤后屈肘挛缩畸形的方法与效果。[方法]参考伊里扎洛夫技术研制了环状弹性肘关节牵伸器,2003年3月~2005年7月治疗肘关节屈曲挛缩畸形3例,男1例,女2例,年龄16~17岁。平均病程12年4个月,术前屈肘畸形(以肘伸直0°位计算)1例70°,2例45°。手术操作不做皮肤切口,仅是在上肢实施穿针、安装外固定关节牵伸器的过程,注意牵伸器的关节铰链对准肘关节的伸屈旋转中心。术后逐渐旋转肘关节前的螺纹牵伸杆,使其产生持续的牵伸力,缓慢矫正屈肘挛缩畸形,在牵伸矫正过程中,定期X线检查肘关节的位置。[结果]3例病人术后牵伸平均32d,肘关节最终伸直到0°~10°位,平均矫正屈肘挛缩45°,肘关节屈伸运动弧从术前75°增加到115°,外观与功能皆达到满意结果。[结论]肘关节微创牵伸成形术可有效的矫正肘关节屈曲挛缩畸形,改善肘关节功能。     

Continuous passive motion versus immobilization. The effect on posttraumatic joint stiffness

Management of intraarticular fractures is often complicated by joint stiffness long after bony healing has occurred. The following experiments provide biomechanical evidence for the effectiveness of CPM in maintaining joint function in stabilized articular injuries. The ankles of ten adolescent New Zealand white rabbits were penetrated by Steinmann pins to create an intraarticular injury. One limb of each animal was immobilized, and the contralateral limb was placed in a continuous passive motion (CPM) machine for three weeks. Joint stiffness of each ankle was quantified with an arthrograph before injury and after three weeks of treatment. Hindlimb volumes were recorded before injury and monitored at weekly intervals using a water-displacement method. Joint stiffness increased 2.6 times the preinjury levels in limbs that were immobilized for three weeks. There was no statistically significant increase in joint stiffness in ankles treated with CPM compared to preinjury values. The posttraumatic difference between the CPM-treated and immobilized limbs was highly significant; limb swelling was not affected by CPM.     

关节镜下肘关节松解术

目的探讨关节镜下松解治疗肘关节活动受限的适应证、临床疗效及预后。方法2003年12月至2005年5月间收治17例创伤后肘关节活动受限患者,关节镜下行肘关节松解术。术中清理关节腔,清除骨赘及影响活动的骨性阻挡,去除鹰嘴窝内瘢痕,松解挛缩的关节囊,恢复肘关节活动度。术后镇痛泵配合下进行康复训练及理疗。对比手术前后肘关节伸屈活动度,行Mayo评分,并观察术后并发症。结果术后随访7～18个月(平均9.7个月),17例患者肘关节活动度均有不同程度改善。术后最大主动伸直位角度平均为5°±5°,较术前改善36°±19°;术后最大主动屈曲位角度平均为113°±21°,较术前增加28°±18°。手术前后最大主动伸直位及屈曲位角度差异有统计学意义(P<0.01)。Mayo评分:术前,良3例,中10例,差4例;术后,优4例,良6例,中6例,差1例。除1例患者术后出现一过性尺神经麻痹,无其他并发症。结论关节镜下肘关节松解术具有创伤小、出血少、并发症少的特点,配合合理的康复训练,能显著改善肘关节的功能,是治疗肘关节活动受限的有效术式。     

The effect of medial collateral ligament repair tension on elbow joint kinematics and stability

PURPOSE: Medial collateral ligament (MCL) repair is commonly performed for the management of acute or subacute instability after elbow dislocations and fracture-dislocations. The effectiveness of transosseous repair of the MCL, as is typically performed clinically, in restoring the normal kinematics and stability of the elbow is of interest as is the effect of MCL tensioning on the initial stability of the elbow. The purpose of this study was to determine whether suture repair of the MCL is able to restore the normal kinematics and stability of the elbow and to determine the optimal initial MCL repair tension. METHODS: Six cadaveric upper extremities were mounted in an upper limb joint simulator. Simulated active and passive elbow flexion was generated while the kinematics were measured with the arm in the dependent and the valgus gravity-loaded orientations. After testing the intact elbow, the MCL was released at its humeral attachment and repaired using a transosseous suture technique at three different repair tensions: 20, 40, and 60 N. RESULTS: Medial collateral ligament repair using a transosseous suture technique restored the kinematics and stability of the MCL-deficient elbow. Motion pathways were affected by the magnitude of initial MCL tension. For all arm orientations and forearm positions, the 20-N and 40-N repairs were not statistically different from each other or from the intact MCL. The 60-N repairs, however, were often statistically different than the other groups, suggesting an overtightening that tended to pull the ulna into a varus position-especially in the midrange of flexion. CONCLUSIONS: These data suggest that MCL repair using transosseous sutures provide adequate joint stability to permit early motion. There is a broad range of acceptable tensions for MCL repair, which is a favorable, clinically relevant finding. Clinical studies are needed to validate these in vitro results.     

Collecting shoulder kinematics with electromagnetic tracking systems and digital inclinometers: A review

The shoulder complex presents unique challenges for measuring motion as the scapula, unlike any other bony segment in the body, glides and rotates underneath layers of soft tissue and skin. The ability for clinicians and researchers to collect meaningful kinematic data is dependent on the reliability and validity of the instrumentation utilized. The aim of this study was to review the relevant literature pertaining to the reliability and validity of electromagnetic tracking systems (ETS) and digital inclinometers for assessing shoulder complex motion. Advances in technology have led to the development of biomechanical instrumentation, like ETS, that allow for the collection of three-dimensional kinematic data. The existing evidence has demonstrated that ETS are reliable and valid instruments for collecting static and dynamic kinematic data of the shoulder complex. Similarly, digital inclinometers have become increasingly popular among clinicians due to their cost effectiveness and practical use in the clinical setting. The existing evidence supports the use of digital inclinometers for the collection of shoulder complex kinematics as these instruments have been demonstrated to yield acceptable reliability and validity. While digital inclinometers pose a disadvantage to ETS regarding accuracy, precision, and are limited to two-dimensional and static measurements, this instrument provides clinically meaningful data that allow clinicians and researchers the ability to measure, monitor, and compare shoulder complex kinematics.     

Anterior capsulotomy and continuous passive motion in the treatment of post-traumatic flexion contracture of the elbow. A prospective study.

Thirty-three patients who had a post-traumatic flexion contracture of the elbow were managed consecutively with anterior capsulotomy without tenotomy of the biceps tendon or myotomy of the brachialis muscle. The first fifteen patients (Group I) did not receive continuous passive motion postoperatively. Preoperative active extension for Group I was to an average of 48 degrees short of full extension, which improved to 19 degrees at a mean follow-up time of forty-five months. Subsequently, eighteen patients (Group II) received continuous passive motion postoperatively for a mean of six weeks. Preoperative active extension for Group II was to an average of 55 degrees short of full extension, which improved to 23 degrees at a mean duration of follow-up of thirty-five months. The mean preoperative arc of motion for Group I was 69 degrees, which improved to 94 degrees postoperatively. The mean preoperative arc of motion for Group II was 48 degrees, which improved to 95 degrees postoperatively. Five patients in Group I and six patients in Group II had severe preoperative heterotopic ossification. There was no correlation, however, between preoperative heterotopic ossification and the amount that extension of the elbow improved postoperatively. There was no postoperative increase in heterotopic ossification. Four patients in Group I and six patients in Group II had severe post-traumatic osteoarthrosis preoperatively. Anterior capsulotomy is an effective treatment of post-traumatic flexion contracture of the elbow. Although the postoperative use of continuous passive motion did not significantly improve mean active extension, it did improve active flexion and the total arc of motion.     

Use of electromagnetic feedback in the rehabilitation of children with injuries of the elbow joint

The paper is devoted to the non-drug functional treatment of children with elbow joint damages by the use of portable self-contained device, based on the principle of electromagnetic feedback. It is demonstrated that sending of artificial feedback signals (light, sound) at the moment of arbitrary contraction of the muscles being trained during 8-10 treatment procedures ensures restoration of muscular-articular sense, strength, endurance of weakened muscle groups, normalizes volume of motion in the elbow joint.     

上臂主动和被动抬高过程中盂-肱关系的动态观察

目的　运用开放MRI和三维数据后处理技术分析主动和被动上臂抬高过程中肱骨头相对于肩胛盂的变换过程。方法　选择 16名健康志愿者 ,用开放MRI分别在肌肉放松 (外展 30°～ 15 0°)和肩部肌肉参与活动 (6 0°～ 12 0°)两种情况下、不同的外展位置上进行检查 ,在断层和三维重建后 ,关节盂的中心点、肱骨头的中心点被确定下来 ,再计算两者之间的相对位置变化。结果　在被动抬高过程中 ,自外展 30°到外展 15 0° ,肱骨头从下方 +1 5 8mm转移到下方 +0 36mm位置 ,自后方 +1 5 5 转移到 - 0 0 7mm。肌肉的参与导致盂 -肱关节变换关系的显著改变 ,肱骨头更加偏向下方和靠近中心 ,特别在 90°和 12 0°外展时表现得最为明显 (P <0 0 1)。前后方向在肌肉的参与下 ,6 0°和 90°外展时 ,肱骨头更趋向中心。结论　神经 -肌肉的控制作用对于保证关节稳定性具有重要作用 ,该组数据也可用于研究神经 -肌肉功能障碍对于肩关节的影响及二者之间的生物力学相关性。     

Measurement of spinal range of motion in healthy individuals using an electromagnetic tracking device

OBJECT: The authors measured the range of motion (ROM) of the spine in healthy individuals by using an electromagnetic tracking device to evaluate the functional performance of the spine. METHODS: The authors used the Flock of Birds electromagnetic tracking device with 4 receiver units attached to C-7, T-12, S-1, and the midthigh region. Forward/backward bending, bilateral side bending, and axial rotation of the trunk were performed in 18 healthy individuals. RESULTS: The average ROM was calculated after 3 consecutive measurements. The thoracic spine generated the greatest angle in axial rotation and smallest angle in backward bending. The lumbar spine generated the greatest angle in forward bending and smallest angle in axial rotation. The hip joints generated the greatest angle in forward bending and smallest angle in backward bending. Additionally, 40% of forward-bending motion occurred in the lumbar spine and 40% occurred in the hip joints. Approximately 60% of backward bending occurred in the lumbar spine; 60% of axial rotation occurred in the thoracic spine; and 45% of side bending occurred in the thoracic spine. CONCLUSIONS: The Flock of Birds electromagnetic tracking device cannot only measure the ROM of spine but also easily differentiate the 6-degree contributions by different segments.     

The use of electromagnetic motion tracking analysis to objectively measure open surgical skill in the laboratory-based model.

BACKGROUND: Technical performance has traditionally been assessed subjectively within the operating theater, with few successful attempts at objective analysis. The Imperial College Surgical Assessment Device (ICSAD) has already been shown to be a valid quantitative measure of dexterity in laparoscopic surgical simulation. We describe its application to the assessment of open surgical procedures. STUDY DESIGN: Fifty-one participants were recruited from four different levels of general surgical experience: basic surgical trainees (n = 12), junior specialist registrars (n = 13), senior specialist registrars (n = 13), and consultants (n = 13). They completed two tasks: a small bowel anastomosis and a vein patch insertion into an artery. Surgical performance was measured with the Imperial College Surgical Assessment Device, a motion analysis system that measures the number of hand movements made and time taken to complete a task. The four groups were compared statistically using the Kruskal-Wallis test (K-W). Pairwise group comparisons used the Mann-Whitney U test and p values were adjusted for multiple comparisons to determine the statistical significance of these comparisons. RESULTS: Mean values for number of movements and time (secs) for small bowel anastomosis were 2,080/1,236 (basic surgical trainees), 1,673/1,016 (junior specialist registrars), 1,375/862 (senior specialist registrars), and 1,337/782 (consultants), respectively. Comparison of the medians by K-W revealed a p < 0.001 for each variable (No. of movements, time), respectively. Mean vein patch insertion results were 1,653/1,258, 1,297/1,006, 1,090/912, and 925/736 for each of the four groups. Again, comparison of the medians by K-W revealed a p < 0.001 for each variable. CONCLUSIONS: These findings suggest that hand motion analysis may be an effective objective measure of dexterity in open surgical simulation.