Myotendinous lengthening of the elbow flexor muscles to improve active motion in patients with elbow spasticity following brain injury

Elbow Flexor Release Combined With Selective Neurectomy of Musculocutaneous Nerve for Spastic Elbow Flexion Deformity in Children and Adolescents

BACKGROUND

Spasticity of the elbow flexors causes a dynamic and/or static elbow flexion deformity. This position interferes with the functional use of the hand, is aesthetically unpleasant and can cause problems with hygiene and comfort. A lengthening procedure of elbow flexor muscles can improve elbow posture and range of motion. However, causal spasticity is not addressed directly. Selective neurectomy of the musculocutaneous nerve has a direct effect on underlying spasticity but is not sufficient when contracture is present. In this study, we examine the long-term results of a combined surgical approach: a release procedure of the elbow flexors and selective neurectomy of the musculocutaneous nerve.

METHODS

A retrospective study of 14 patients with spastic flexion deformity of the elbow was performed. After a mean follow-up of 52.6 months (SD 33, range 12 to 113), the results of the combined surgical approach were evaluated. Spontaneous position of the elbow and active and passive range of motion were assesses using goniometry. Spasticity was assessed using the Modified Ashworth Scale. Function of the affected upper limb before and after surgery was assessed by the House functional classification. Patient and caretaker's satisfaction were assessed using a visual analogue scale.

RESULTS

The mean decrease of passive elbow extension deficit was 34 degrees (SD 21.3, P<0.05). Active elbow extension increased with a mean of 41 degrees (SD 16.5, P<0.05). Spontaneous position elbow flexion decreased by a mean of 40 degrees (SD 21.1, P<0.05).The Modified Ashworth score decreased significantly (P<0.05) from 3.27 (range 1 to 4) preoperatively to 0.64 (range 0 to 4) postoperatively.The difference between the House score preoperatively and postoperatively was not significant (P=0.180). Mean patient satisfaction was 8.2/10 (SD 2.7, range 2 to 10) and mean caregiver satisfaction was 7.1/10 (SD 2.7, range 1 to 10).

CONCLUSION

A combined surgical approach to elbow flexion deformity in the form of a lengthening procedure and selective neurectomy of the elbow flexors result in a significant and sustained improvement of the spontaneous position, active and passive elbow extension and elbow flexor spasticity and high patient and caregiver satisfaction.

LEVEL OF EVIDENCE

Case series, level IV.

Surgical Treatment in Post-Stroke Spastic Hands: A Systematic Review

Background: For more than two decades, the surgical treatment of post-stroke spastic hands has been displaced by botulinum toxin therapy and is currently underutilized. Objectives: This article aimed to assess the potential of surgery for treating a post-stroke spastic upper extremity through a systematic review of the literature on surgical approaches that are adopted in different profiles of patients and on their outcomes and complications. Methods: Medline PubMed, Web of Science, SCOPUS, and Cochrane Library databases were searched for observational and experimental studies published in English up to November 2022. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluations (GRADE) system. Results: The search retrieved 501 abstracts, and 22 articles were finally selected. The GRADE-assessed quality of evidence was low or very low. The results of the reviewed studies suggest that surgery is a useful, safe, and enduring treatment for post-stroke spastic upper extremities, although most studied patients were candidates for hygienic improvements alone. Patients usually require an individualized combination of techniques. Over the past ten years, interest has grown in procedures that act on the peripheral nerve. Conclusions: Despite the lack of comparative studies on the effectiveness, safety, and cost of the treatments, botulinum toxin has displaced surgery for these patients. Studies to date have found surgery to be an effective and safe approach, but their weak design yields only poor-quality evidence, and clinical trials are warranted to compare these treatment options.

Surgical management of the spastic elbow

Background

We performed a retrospective review of patients undergoing surgery for elbow spasticity. We present our findings and expected outcomes according to degree of elbow fixed flexion contracture.

Methods

Data collected included age, Modified Ashworth Score, pre and post-operative range of motion, indications for surgery and the Goal Attainment Score. Contracture severity was classified into five groups based on goniometric measurements. Surgical procedures were categorised into three groups.

Results

A total of 114 elbows underwent surgical release. The mean age at surgery was 18.5 years and the mean follow-up was 20 months. Preoperatively, the median Modified Ashworth Score was 2 and the mean contracture was 68° (35° fixed and 33° dynamic). The median number of structures released was 3 (range: 1-6). Surgical procedures were classified as biceps sparing (27%), biceps lengthening (53%) and extended releases (18%). Mean improvement in extension was 59°, and the mean improvement in Goal Attainment Score was 36 (mean attainment score 62). The mean residual contracture was 9°. Patient satisfaction was high with over 90% of surgical indications met.

Discussion

Contracture severity of the spastic elbow can be categorised by degree of fixed flexion deformity and therefore treatment can be allocated accordingly.

Flexor tenotomies for the treatment of bilateral wrist contracture after traumatic brain injury: A case report

Traumatic brain injuries have the potential to cause the development of long-term complications. We aim to show that the use of flexor tenotomies in the treatment of flexion contractures following traumatic brain injury is a viable solution.

Technique and biomechanical properties of the side-to-side Z-lengthening in spasticity-correcting surgery- a study on porcine tendons

Spasticity-correcting surgery in patients with injuries to upper motor neurons include various techniques, including tenotomies and lengthening of tendons of spastic muscles. Early mobilization including active loading of a lengthened tendon is essential to prevent adhesion formation, which necessitates a lengthening technique that resists the forces produced by the involved muscles. This study on animal tendons reports the biomechanical properties in regards to elongation and load to failure in porcine tendons lengthened by either a 3 or 5 cm overlap and tested in a simple force rig. The lengthening technique used in these tendons is described in step-by-step detail. The mean elongation of 20 lengthened tendons at 100 N was 10 mm for tendons with a 3 cm overlap and 6 mm for tendons with a 5 cm overlap. The mean peak load at failure of the construct was 138 N for lenghened tendons with a 3 cm overlap and 201 N for tendons with a 5 cm overlap. The results of this study indicate that a tendon lengthened by the described technique with a mere overlap of three cm will withstand the estimated forces elicited by muscles in the forearm immediately after surgery.

Treatment of upper extremity palsies, gunshot wounds and scaphoid nonunion: my preferred approaches

The article reviews key considerations and our preferred methods in treating upper extremity palsies, gunshot wounds and scaphoid nonunion. For these three difficult conditions, I highlight the importance of a team approach when treating upper extremity neuromuscular disease, flexibility and creativity when treating gunshot wounds, and my personal protocol for dealing with scaphoid fracture nonunions.Level of evidence: V.

Effect of Stretching of Spastic Elbow Under Intelligent Control in Chronic Stroke Survivors-A Pilot Study

Objective: To assess the short-term effects of strenuous dynamic stretching of the elbow joint using an intelligent stretching device in chronic spastic stroke survivors.

Methods: The intelligent stretching device was utilized to provide a single session of intensive stretching to the spastic elbow joint in the sagittal plane (i.e., elbow flexion and extension). The stretching was provided to the extreme range, safely, with control of the stretching velocity and torque to increase the joint range of motion (ROM) and reduce spasticity and joint stiffness. Eight chronic stroke survivors (age: 52.6 ± 8.2 years, post-stroke duration: 9.5 ± 3.6 years) completed a single 40-min stretching intervention session. Elbow passive and active ROM, strength, passive stiffness (quantifying the non-reflex component of spasticity), and instrumented tendon reflex test of the biceps tendon (quantifying the reflex component of the spasticity) were measured before and after stretching.

Results: After stretching, there was a significant increase in passive ROM of elbow flexion (p = 0.021, r = 0.59) and extension (p = 0.026, r = 0.59). Also, elbow active ROM and the spastic elbow flexors showed a trend of increase in their strength.

Conclusion: The intelligent stretching had a short-term positive influence on the passive movement ROM. Hence, intelligent stretching can potentially be used to repeatedly and regularly stretch spastic elbow joints, which subsequently helps to reduce upper limb impairments post-stroke.

Surgical Approaches to Upper Limb Spasticity in Adult Patients: A Literature Review

Introduction: Spasticity is the main complication of many upper motor neuron disorders. Many studies describe neuro-orthopedic surgeries for the correction of joint and limb deformities due to spasticity, though less in the upper extremity. The bulk of care provided to patients with spasticity is provided by rehabilitation clinicians, however, few of the surgical outcomes have been summarized or appraised in the rehabilitation literature.

Objective: To review the literature for neuro-orthopedic surgical techniques in the upper limb and evaluate the level of evidence for their efficacy in adult patients with spasticity.

Method: Electronic databases of MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews were searched for English, French as well as Farsi languages human studies from 1980 to July 2, 2020. After removing duplicated articles, 2,855 studies were screened and 80 were found to be included based on the criteria. The studies were then divided into two groups, with 40 in each trial and non-trial. The results of the 40 trial articles were summarized in three groups: shoulder, elbow and forearm, and wrist and finger, and each group was subdivided based on the types of intervention.

Results: The level of evidence was evaluated by Sackett's approach. There were no randomized control trial studies found. About, 4 studies for shoulder, 8 studies for elbow and forearm, 26 studies for wrist and finger (including 4 for the thumb in palm deformity), and 2 systematic reviews were found. Around, two out of 40 trial articles were published in the rehabilitation journals, one systematic review in Cochrane, and the remaining 38 were published in the surgical journals.

Conclusion: Most surgical procedures are complex, consisting of several techniques based on the problems and goals of the patient. This complexity interferes with the evaluation of every single procedure. Heterogenicity of the participants and the absence of clinical trial studies are other factors of not having a single conclusion. This review reveals that almost all the studies suggested good results after the surgery in carefully selected cases with goals of reducing spasticity and improvement in function, pain, hygiene, and appearance. A more unified approach and criteria are needed to facilitate a collaborative, evidence-based, patient referral, and surgical selection pathway.

Preferred options and evidence for upper limb surgery for spasticity in cerebral palsy, stroke, and brain injury

Surgical interventions for the spastic upper extremity secondary to stroke, traumatic brain injury, and cerebral palsy aim to correct the common deformities of elbow flexion, forearm pronation, wrist and finger flexion, ulnar deviation, and thumb-in-palm deformity. After appropriate evaluation, as well as determining the goals of surgery, deformity correction can be achieved through single-event, multi-level surgery. Surgery includes a combination of soft tissue lengthening, tendon transfer, and joint stabilization procedures. Surgical treatment for shoulder adduction/internal rotation, elbow flexion, forearm pronation, wrist flexion, thumb-in-palm, and clenched fist deformities due to spasticity are discussed, and treatment outcomes are reviewed.

Surgical Management of Upper Extremity Deformities in Patients With Upper Motor Neuron Syndrome

Injury to the central nervous system can create upper extremity deformities and dysfunction, typically caused by a cerebrovascular accident, traumatic brain injury, anoxic brain injury, or spinal cord injury. Regardless of the etiology, disruption of inhibitory upper motor neuron (UMN) pathways can lead to a constellation of symptoms such as muscle weakness, decreased motor control, hyperexcitable tendon reflexes, muscle spasticity, and agonist-antagonist cocontraction that characterizes a condition known as UMN syndrome. The magnitude of neurorecovery varies among patients who have sustained brain injuries and can be classified as having a functional or nonfunctional upper extremity based on the presence or absence of volitional motor control at a specific joint, respectively. Many surgical procedures can be employed to optimize function, decrease pain, improve hygiene, and enhance cosmesis in patients with UMN syndrome.

Management of Spinal Cord Injury-Induced Upper Extremity Spasticity

Spasticity affects more than 80% of patients with spinal cord injury. Neural mechanisms and musculotendinous alterations lead to typical upper extremity features including shoulder adduction/internal rotation, forearm pronation, and elbow, wrist, and finger flexion. Long-standing spasticity may lead to soft tissue and joint contractures and further impairment of upper extremity function. Surgical management involves tendon lengthening, release, and transfer, as well as selective neurotomy, in an effort to reduce spastic muscle hypertonicity, restore balance, prevent further contracture, and improve posture and function. This article summarizes surgical strategies to improve function of the upper extremity in patients with tetraplegia.

Rehabilitation Strategies Following Surgical Treatment of Upper Extremity Spasticity

Upper motor neuron injuries that occur in cases such as cerebral palsy, cerebrovascular accidents, and traumatic brain injury often have resulting upper extremity deformity and dysfunction. Multiple surgical options are available to improve upper extremity positioning, and, in some cases, motor control. Postoperative therapeutic management is imperative to assist the patient/caregiver in maximizing potential functional gains. This article provides an overview of postoperative guidelines for commonly performed surgeries to manage upper extremity dysfunction caused by spasticity and discusses acute management as well as therapeutic techniques for functional training and improved motor control.

Management of Joint Contractures in the Spastic Upper Extremity

Upper extremity contractures in the spastic patient may result from muscle spasticity, secondary muscle contracture, or joint contracture. Knowledge of the underlying cause is critical in planning successful treatment. Initial management consists of physical therapy and splinting. Botulinum toxin can be helpful, as a therapeutic treatment in relieving spasticity and as a diagnostic tool in determining the underlying cause of the contracture. Surgical management options include release or lengthening of the causative muscle/tendon unit and joint capsular release, as required. Postoperative splinting is important to maintain the improved range of motion and protect any associated tendon lengthening or transfer.

Open arthrolysis with pie-crusting release of the triceps tendon for treating post-traumatic contracture of the elbow

BACKGROUND

Extensive loss of elbow flexion compromises the performance of daily activities. We examined the clinical outcomes of patients with post-traumatic extension contracture of the elbow treated with open arthrolysis and pie-crusting release of the triceps tendon.

METHODS

We retrospectively reviewed the records of 7 patients (5 men and 2 women; mean age, 35 years) who underwent open arthrolysis via a combined lateral and medial approach with pie-crusting release of the triceps tendon for the treatment of post-traumatic elbow stiffness. All the patients had heterotopic ossification that restricted elbow motion and underwent removal of the ossified tissue and capsular release. The triceps tendon was gradually stretched by making multiple stab incisions on the tendon by using a No. 11 surgical blade. The range of motion of the elbow was recorded both preoperatively and at the final postoperative follow-up. Elbow function was assessed with the Mayo Elbow Performance Score.

RESULTS

The patients were followed up for a mean of 24 months. After treatment, significant improvement was noted in the total arc of motion (from 44° to 116°, P <.001), mean flexion (from 80° to 124°, P < .001), and mean extension (from 31° to 8°, P = .004). The mean Mayo Elbow Performance Score improved significantly from 59 points preoperatively to 92 points at the final evaluation. No major postoperative complications developed in any of the patients.

CONCLUSION

Our findings indicate that open arthrolysis with pie-crusting release of the triceps tendon is an effective and safe treatment approach for post-traumatic extension contracture of the elbow.