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Esworthy GP, Shaji V, Duraku L, Wu F, Power DM. Bridge Plate Distraction for Complex Distal Radius Fractures: A Cohort Study and Systematic Review of the Literature. J Wrist Surg 2024; 13:282-292. [PMID: 38808186 PMCID: PMC11129887 DOI: 10.1055/s-0043-1770791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 05/22/2023] [Indexed: 05/30/2024]
Abstract
Background Dorsal bridge plating (DP) of the distal radius is used as a definitive method of stabilization in complex fracture configurations and polytrauma patients. Questions/Purposes This review aims to summarize the current understanding of DP and evaluate surgical outcomes. Methods Four databases were searched following the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines and registered with PROSPERO. Papers presenting outcome or complication data for DP were included. These were reviewed using the National Institutes of Health Quality Assessment and Methodological Index for Non-Randomised Studies tools. Results were collated and compared to a local cohort of DP patients. Results Literature review identified 416 patients with a pooled complication rate of 17% requiring additional intervention. The most prevalent complications were infection/wound healing issues, arthrosis, and hardware failure. Average range of motion was flexion 46.5 degrees, extension 50.7 degrees, ulnar deviation 21.4 degrees, radial deviation 17.3 degrees, pronation 75.8 degrees, and supination 72.9 degrees. On average, DP removal occurred at 3.8 months. Quality assessment showed varied results. There were 19 cases in our local cohort. Ten displayed similar results to the systematic review in terms of range of motion and radiographic parameters. Higher QuickDASH scores and complication rates were noted. Local DP showed earlier plate removal at 2.9 months compared to previous studies. Conclusion DP is a valid and useful technique for treating complex distal radius fractures. It displays a lower risk of infection and pain compared to external fixation which is commonly used to treat similar injuries. Patients can recover well following treatment both in function and range of motion. Further high-quality studies are required to fully evaluate the technique.
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Affiliation(s)
- George P. Esworthy
- Birmingham Hand Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Untied Kingdom
- Leicester Medical School, University of Leicester, Leicester, United Kingdom
| | - Vibha Shaji
- Leicester Medical School, University of Leicester, Leicester, United Kingdom
| | - Liron Duraku
- Birmingham Hand Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Untied Kingdom
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam, Netherlands
| | - Feiran Wu
- Birmingham Hand Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Untied Kingdom
| | - Dominic M. Power
- Birmingham Hand Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Untied Kingdom
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Pyörny J, Luukinen P, Sletten IN, Reito A, Leppänen OV, Jokihaara J. Is Replantation Associated With Better Hand Function After Traumatic Hand Amputation Than After Revision Amputation? Clin Orthop Relat Res 2024; 482:843-853. [PMID: 37921614 PMCID: PMC11008649 DOI: 10.1097/corr.0000000000002906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 09/29/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Replantation is an established treatment for traumatic upper extremity amputation. Only a few studies, however, have assessed the patient-reported outcomes of replantation, and the findings of these studies have been conflicting. QUESTIONS/PURPOSES (1) Is replantation associated with better hand function than revision amputation? (2) Is replantation associated with better health-related quality of life, less painful cold intolerance, and more pleasing hand esthetics than revision amputation after a traumatic hand amputation? METHODS In this retrospective, comparative study, we collected the details of all patients who sustained a traumatic upper extremity amputation and were treated at the study hospital. Between 2009 and 2019, we treated 2250 patients, and we considered all patients who sustained a traumatic amputation of two or more digital rays or a thumb as potentially eligible. Based on that, 15% (334 of 2250) were eligible; a further 2% (8 of 334) were excluded because of a subsequent new traumatic amputation or bilateral amputation, and another 22% (72 of 334) refused participation, leaving 76% (254 of 334) for analysis here. The primary outcome was the DASH score. Secondary outcomes included health-related quality of life (EuroQOL-5D [EQ-5D-5L] Index), painful cold intolerance (the Cold Intolerance Symptom Severity score), and hand esthetics (the Michigan Hand Questionnaire aesthetic domain score). The minimum follow-up time for inclusion was 18 months. Patients were classified into two treatment groups: replantation (67% [171 of 254], including successful replantation in 84% [144 of 171] and partially successful replantation in 16% [27 of 171], in which some but not all of the replanted tissue survived), and revision (complete) amputation (33% [83 of 254], including primary revision amputation in 70% [58 of 83] and unsuccessful replantation followed by secondary amputation in 30% [25 of 83]). In this cohort, replantation was performed if possible, and the reason for choosing primary revision amputation over replantation was usually an amputated part that was too severely damaged (15% [39 of 254]) or was unattainable (2% [4 of 254]). Some patients (3% [8 of 254]) refused to undergo replantation, or their health status did not allow replantation surgery and postoperative rehabilitation (3% [7 of 254]). Gender, age (mean 48 ± 17 years in the replantation group versus 50 ± 23 years in the revision amputation group; p = 0.41), follow-up time (8 ± 4 years in the replantation group versus 7 ± 4 years in the revision amputation group; p = 0.18), amputation of the dominant hand, smoking, extent of tissue loss, or presence of arterial hypertension did not differ between the groups. Patients in the replantation group less frequently had diabetes mellitus (5% [8 of 171] versus 12% [10 of 83]; p = 0.03) and dyslipidemia (4% [7 of 171] versus 11% [9 of 83]; p = 0.04) than those in the revision group and more often had cut-type injuries (75% [129 of 171] versus 60% [50 of 83]; p = 0.02). RESULTS After controlling for potential confounding variables such as age, injury type, extent of tissue loss before treatment, and accident of the dominant hand, replantation was not associated with better DASH scores than revision amputation (OR 0.82 [95% confidence interval (CI) 0.50 to 1.33]; p = 0.42). After controlling for potential cofounding variables, replantation was not associated with better EQ-5D-5L Index scores (OR 0.93 [95% CI 0.56 to 1.55]; p = 0.55), differences in Cold Intolerance Symptom Severity scores (OR 0.85 [95% CI 0.51 to 1.44]; p = 0.79), or superior Michigan Hand Questionnaire esthetic domain scores (OR 0.73 [95% CI 0.43 to 1.26]; p = 0.26) compared with revision amputation. CONCLUSION Replantation surgery was conducted, if feasible, in a homogenous cohort of patients who underwent amputation. If the amputated tissue was too severely damaged or replantation surgery was unsuccessful, the treatment resulted in revision (complete) amputation, which was not associated with worse patient-reported outcomes than successful replantation. These results contradict the assumed benefits of replantation surgery and indicate the need for credible evidence to better guide the care of these patients. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Joonas Pyörny
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Patrick Luukinen
- Center for Musculoskeletal Diseases, Tampere University Hospital, Tampere, Finland
| | | | - Aleksi Reito
- Center for Musculoskeletal Diseases, Tampere University Hospital, Tampere, Finland
| | - Olli V. Leppänen
- Center for Musculoskeletal Diseases, Tampere University Hospital, Tampere, Finland
| | - Jarkko Jokihaara
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Center for Musculoskeletal Diseases, Tampere University Hospital, Tampere, Finland
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3
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Yu JT, Huang YC, Chen CS. Research and Development of a 3D-Printed Dynamic Finger Flexion Orthosis for Finger Extension Stiffness-A Preliminary Study. Bioengineering (Basel) 2024; 11:339. [PMID: 38671761 PMCID: PMC11048443 DOI: 10.3390/bioengineering11040339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 04/28/2024] Open
Abstract
Finger extension stiffness is a common post-traumatic complication that results in the hand's functional impairment. In clinical practice, a dynamic splint enables the patient to stretch the affected finger independently. However, current dynamic splints have drawbacks, such as limited stretching efficacy, and interfere with the hand's functional activities. Therefore, this study aimed to develop a dynamic finger flexion orthosis capable of stretching each finger joint using additive manufacturing (AM) technology, thereby enabling hand functional activity, and analyze the clinical improvement in the range of motion (ROM). One subject with a hand fracture was recruited while undergoing a 7-week home-based rehabilitation program for the orthosis. The outcome measurements included the total active motion (TAM), the tip-to-finger distance (TPD), and the score on the Disability of Arm, Shoulder, and Hand (DASH) questionnaire. The results show that the TAM of the participant's fingers increased by 72.7 degrees on average, the TPD decreased by 3.5 cm on average, and the DASH score decreased to 9.5 points. The 7-week home-based rehabilitation program for the orthosis resulted in a 53.6% increase in the TAM on average. The developed orthosis improved hand function and enabled a more complete ROM in finger flexion.
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Affiliation(s)
- June-Tzu Yu
- Department of Physical Therapy and Assistive Technology, National Yang Ming Chiao Tung University, Taipei 112, Taiwan;
| | - Yi-Chao Huang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei 112, Taiwan
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Chen-Sheng Chen
- Department of Physical Therapy and Assistive Technology, National Yang Ming Chiao Tung University, Taipei 112, Taiwan;
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Pyörny J, Karelson M, Sletten IN, Ukkola A, Jokihaara J. Patient-reported significant disability after major traumatic upper extremity amputation. J Hand Surg Eur Vol 2023:17531934231215791. [PMID: 37994012 DOI: 10.1177/17531934231215791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
The aims of this study were to record patient-reported outcomes of treatment of proximal upper extremity amputation injuries and subsequent return to work. A consecutive cohort of 38 patients with a traumatic amputation at or proximal to the carpus had been treated with a replantation or revision (completion) amputation in Tampere University Hospital between 2009 and 2019, and 31 of them participated in this study. The primary outcome was the Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH). Patients reported significant disability indicated by DASH score after replantation (median 30; interquartile range [IQR] 21-47) and revision (completion) amputation (median 33; IQR 16-52). Most patients had cold intolerance and reported low hand function and aesthetics scores. Out of 17 working patients, 10 did not return to their previous work. Our study demonstrates the influence of major upper extremity amputation on daily life activities, even after a successful replantation.Level of evidence: IV.
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Affiliation(s)
- Joonas Pyörny
- Faculty of Medicine and Health Technology, Tampere University, Finland
| | - Margit Karelson
- Center for Musculoskeletal Diseases, Tampere University Hospital, Tampere, Finland
| | | | - Anniina Ukkola
- Center for Musculoskeletal Diseases, Tampere University Hospital, Tampere, Finland
| | - Jarkko Jokihaara
- Faculty of Medicine and Health Technology, Tampere University, Finland
- Center for Musculoskeletal Diseases, Tampere University Hospital, Tampere, Finland
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Pelet S, Hardy A, Tremblay F, Lechasseur B, Rivard-Cloutier M. Prognostic Factors of Function in Nonoperatively Treated Radial Head Fractures: A Prospective Cohort Study. J Orthop Trauma 2023; 37:e429-e434. [PMID: 37448159 DOI: 10.1097/bot.0000000000002660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVES To identify patient-related factors and fracture characteristics influencing the functional outcomes of nonoperatively treated radial head fractures and to determine function at 1 year. DESIGN Prospective cohort study. SETTING Academic Level 1 trauma center. PATIENTS/PARTICIPANTS Consecutive isolated radial head fractures fitting the inclusion criteria between May 2013 and July 2016. INTERVENTION Nonoperative treatment of isolated radial head fractures. OUTCOME MEASUREMENTS Logistic regressions between potential prognostic factors and function assessed with the Mayo Elbow Performance Score (MEPS), the Disabilities of the Arm, Shoulder, and Hand (DASH) score, and range of motion at 1.5-3-6-12 months. RESULTS One hundred fourteen patients were included (78% Mason I [OTA/AO 2R1B1], 20% Mason II [OTA/AO 2R1B3], and 2% Mason III [OTA/AO 2R1C3]). Mean MEPS and DASH score at the last follow-up were excellent [96.4 ± 7.6 and 3.7 ± 8.6] with, respectively, 79.8% and 92.7% of satisfactory results. Depressive symptoms at injury baseline (Quick Inventory of Depressive Symptomatology > 5) are a constant predictor of unsatisfactory function (MEPS <90 or DASH >17]). Older age and female sex were all linked to worse function at the first follow-ups ( P < 0.05), whereas lower socioeconomic class and receiving financial compensations were associated to unsatisfactory function at 1 year ( P < 0.05). CONCLUSIONS Although most nonoperatively treated radial head fractures heal with excellent function, some patients still exhibit unsatisfactory results at 1 year. Symptoms of depression at injury baseline are a constant and significant predictor of unsatisfactory function. Early detection of depressive symptoms would allow for interventions that may optimize function. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Stéphane Pelet
- Department of Orthopedic Surgery, CHU de Québec-Hôpital Enfant-Jésus, Québec, QC, Canada; and
- Centre de recherche FRQS du CHU de Québec, Québec, QC, Canada
| | - Alexandre Hardy
- Department of Orthopedic Surgery, CHU de Québec-Hôpital Enfant-Jésus, Québec, QC, Canada; and
| | - Félix Tremblay
- Department of Orthopedic Surgery, CHU de Québec-Hôpital Enfant-Jésus, Québec, QC, Canada; and
| | - Benoît Lechasseur
- Department of Orthopedic Surgery, CHU de Québec-Hôpital Enfant-Jésus, Québec, QC, Canada; and
| | - Maude Rivard-Cloutier
- Department of Orthopedic Surgery, CHU de Québec-Hôpital Enfant-Jésus, Québec, QC, Canada; and
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Campbell BR, Rengifo S, Wickes CB, Amer KM, Ilyas AM. Radial Head Arthroplasty for Fracture: Implant Survivorship and Outcomes at Mean Follow-up of 8 Years. J Hand Surg Am 2023:S0363-5023(23)00253-8. [PMID: 37354192 DOI: 10.1016/j.jhsa.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/17/2023] [Accepted: 04/26/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE The purpose of this study was to evaluate implant survivorship and clinical outcomes following radial head arthroplasty for fracture at long-term follow-ups. METHODS A retrospective analysis was conducted on adult patients who underwent primary uncemented radial head arthroplasty for radial head or neck fractures between 2012 and 2015. Medical records were reviewed to collect information regarding demographics, injury characteristics, reoperations, and revisions requiring implant removal. A bivariate analysis was conducted to identify potential risk factors for reoperation. A Kaplan-Meier curve was created to determine implant survival rates. Eligible patients were contacted to confirm any reoperations and obtain Quick Disability of the Arm, Shoulder, and Hand scores at long-term follow-ups. RESULTS A total of 89 patients were eligible for analysis and assessed at a mean of 97 months after surgery (range, 81-128). Reoperation rate was 16% (14 of 89 patients), including 5% of patients requiring implant removal or revision. However, 93% of reoperations occurred within the first 12 months of the index surgery. Fracture dislocations of the elbow had a higher rate of reoperation. A Kaplan-Meier curve demonstrated an implant survival rate of 96% at 10-year follow-up. Of the patients who responded, the mean Quick Disability of the Arm, Shoulder, and Hand score was 8.7 ± 10.3, with none requiring additional reoperations or revisions. There were otherwise similar outcome scores among patients requiring reoperation versus those who did not. CONCLUSIONS Although radial head arthroplasty for fractures has a high potential for reoperation within the first year, survival rates with uncemented implants remain high at 10 years, and patients report excellent Quick Disability of the Arm, Shoulder, and Hand scores at long-term follow-ups, despite any need for reoperation. Fractures with associated elbow dislocation may be at a higher risk for reoperation, and it is important to provide this prognostic information to patients who are likely to require arthroplasty for more extensive injuries. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Benjamin R Campbell
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Santiago Rengifo
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Catherine B Wickes
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Kamil M Amer
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Asif M Ilyas
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA.
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Ranganath K, Miller LE, Goss D, Lin DT, Faden DL, Deschler DG, Emerick KS, Richmon JD, Varvares MA, Feng AL. Comparison of patient-reported upper extremity disability following free flaps in head and neck reconstruction: A systematic review and meta-analysis. Head Neck 2023. [PMID: 37129003 DOI: 10.1002/hed.27375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 04/05/2023] [Accepted: 04/08/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND Comparisons of patient-reported donor site morbidity based on the Disabilities in Arm, Shoulder, and Hand (DASH) instrument across upper trunk free flaps in head and neck surgery, including radial forearm (RFFF), osteocutaneous radial forearm (OCRFF), scapular tip (STFF), and serratus anterior (SAFF) free flaps, may help inform donor tissue selection. METHODS In this meta-analysis, 12 studies were included and the primary outcome was average DASH score. RESULTS The pooled DASH scores were 12.14 (95% CI: 7.40-16.88) for RFFF (5 studies), 17.99 (11.87-24.12) for OCRFF (2 studies), 12.19 (8.74-15.64) for STFF (3 studies), and 16.49 (5.92-27.05) for SAFF (2 studies) and were not significantly different. CONCLUSIONS Results suggest that patients generally function well, with minimal to mild donor site morbidity, when assessed at an average of 20 months after flap harvest. These results are based on few effects from primarily retrospective studies of fair quality, and further research is needed.
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Affiliation(s)
- Kushi Ranganath
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Lauren E Miller
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah Goss
- Howe Library, Mass Eye and Ear, Boston, Massachusetts, USA
| | - Derrick T Lin
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel L Faden
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel G Deschler
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Kevin S Emerick
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy D Richmon
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Allen L Feng
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
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Koh ES, Kurillo G, Han JJ, Lim JY. Use of the Kinect sensor measured three-dimensional reachable workspace to assess the upper extremity function in older adults. Clin Biomech (Bristol, Avon) 2022; 99:105767. [PMID: 36150288 DOI: 10.1016/j.clinbiomech.2022.105767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 09/07/2022] [Accepted: 09/12/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND We explored the utility of Kinect sensor-based upper extremity reachable workspace measure in healthy adults aged over 65 years. METHODS Forty-three healthy older subjects (19 men and 24 women) aged over 65 years and 22 healthy young subjects (11 men and 11 women) were included. All participants were ambulatory and perform the activities of daily living independently. Three-dimensional reachable workspace data were acquired for both arms using the Kinect sensor. We evaluated hand grip strength, manual muscle shoulder strength, and the active shoulder ranges of motion of the dominant and non-dominant sides. We assessed upper limb function using the Disabilities of Arm, Shoulder, and Hand (DASH) instrument and the health-related quality of life employing the descriptive EQ-5D-5L system. FINDINGS The quadrant 3 relative surface area in older adults was significantly smaller than that of young adults (both dominant and non-dominant sides), while the total and quadrants 1, 2, and 4 relative surface areas did not differ between older and young adults. However, the quadrant 3 relative surface area did not correlate with the DASH or EQ5D scores. The total and quadrant 1, 2, and 4 relative surface areas of the dominant side significantly correlated with the DASH score. The quadrant 4 relative surface area of the dominant side significantly correlated with the EQ5D score. INTERPRETATION Kinect sensor-based, three-dimensional, reachable workspace analysis may be useful to evaluate upper limb function in older adults.
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Affiliation(s)
- Eun Sil Koh
- Department of Rehabilitation Medicine, National Medical Center, Seoul, Republic of Korea
| | - Gregorij Kurillo
- Department of Orthopaedic Surgery, University of California at San Francisco, San Francisco, CA, United States of America
| | - Jay J Han
- Department of Physical Medicine & Rehabilitation, University of California at Irvine School of Medicine, Irvine, CA, United States of America
| | - Jae-Young Lim
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Institute on Aging, Seoul National University, Seoul, Republic of Korea.
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