No description available.

Hand dominance is the preferential use of one hand over the other for motor tasks. 90% of people are right-hand dominant, and the majority of injuries (acute and cumulative trauma) occur to the dominant limb, creating a double-impact injury whereby a person is left in a functional state of single-handedness and must rely on the less-dexterous, non-dominant hand. When loss of dominant hand function is permanent, a forced shift of dominance is termed injury-induced hand dominance transfer (I-IHDT). Military service members injured in combat operation may face I-IHDT following mutilating injuries (crush, avulsion, burn and blast wounds) that result in dominant limb amputation or limb salvage. Military occupational therapy practitioners utilize an intervention called Handwriting For Heroes to facilitate hand dominance transfer. This intervention trains the injured military member how to write again using the previously non-dominant hand. Efficacy and clinical effectiveness studies were needed to validate the use of this intervention. This dissertation contains three studies related to I-IHDT. One study measured handwriting performance in adults who previously (greater than 2 years ago) lost function of their dominant hands. Results verified that handwriting performance, when measured on two separate occasions (six-weeks apart) was similar (stable). A second study examined the efficacy of Handwriting For Heroes in non-impaired participants. Results demonstrated a positive effect on the variables that measured the written product: legibility, writing speed (letters-per-minute); as well as a positive effect on the variables that measured the writing process: kinematic and kinetic parameters. The final study examined the clinical effectiveness of Handwriting For Heroes in an injured military population. Results did not show as positive results as the efficacy study, despite similar compliance with the intervention. Specifically, non-impaired participants started with faster writing speeds in their non-dominant hands (higher letters-per-minute) and made more gains (wider ranges). The non-impaired participants also started with faster dexterity (betters scores on the Grooved Pegboard) but they made fewer gains than the injured service members (smaller ranges). Nevertheless, injured participants clearly made gains in all dependent variables thereby demonstrating clinical effectiveness of the intervention

Sarcoma cancer of the proximal femur is a bone tumor that develops near the hip joint. The most common method of treatment is limb salvage surgery (LLS), a highly invasive surgery that often leads to impaired movement including walking due to soft tissue resection. The current thesis focuses on 1) systematically reviewing current literature of functional outcomes after proximal femur LSS to determine if specific methods of muscle reattachment lead to better limb function, and 2) objectively analysing how reducing hip muscle strength impacts one’s ability to achieve healthy gait. Findings from the systematic review suggest using artificial mesh or ligaments for LLS may be a good alternative to allograft prosthesis composites and trochanter osteotomy, producing good functional outcomes with low rates of complications. It was also determined current literature is lacking objective quantitative analysis of patients’ limb function after surgery. Objective 2 was executed using instrumented gait analysis to record the gait kinematics, kinetics and EMG patterns of a patient who received LSS for proximal femur sarcoma. Data from the gait analysis was used to create a patient-specific musculoskeletal model. Healthy gait kinematics were applied to the model and specific hip muscle strengths were systematically reduced to simulate different surgical interventions. After an 85% reduction in gluteus medius and minimus muscle strength, healthy gait kinematics were not achieved. Reducing muscle strength of the gluteus medius and minimus together had a greater impact on the model’s ability to achieve healthy gait kinematics then when reduced individually. An understanding of how patient’s limb function is impacted after surgery can inform surgical technique, implant design and physiotherapy programs leading to better quality of life for patients after surgery. / Thesis / Master of Applied Science (MASc) / Hip reconstructive surgery as treatment for bone cancer is a highly invasive surgery that negatively impacts patients walking patterns and ultimately quality of life. The current thesis investigates existing literature to determine if specific, innovative surgical techniques lead to better functional results for patients after surgery. A three-dimensional model of a patient who had hip reconstruction surgery for bone cancer was created using quantitative analysis of their walking patterns. The model was manipulated to simulate surgical intervention for hip cancer treatment. The model findings suggest when specific hip muscles are substantially affected by surgery, patients walking patterns are negatively impacted. Understanding how surgical intervention impacts walking patterns can inform surgical technique, implant design and physiotherapy programs leading to better quality of life for patients after surgery.

The purpose of this investigation was to assess the efficacy of a multifaceted gait analysis approach using a group of twenty osteosarcoma patients who underwent limb salvage surgery. Mean age at time of surgery was 16.1 years (range: 7-29), mean age at time of evaluation was 23.55 years (range: 11-43). Nine patients were treated with a Stryker Howmedica Modular Resection System (Stryker Kalamazoo, USA) and eleven patients were treated with a Stanmore custom made prosthesis (Stanmore implants worldwide Ltd, Stanmore, UK). Ten control participants with a mean age of 24.9 (range: 14-36) were recruited for the study. Ethical approval was gained through The University of Queensland Ethics Committee and The Royal Children’s Hospital and Health Service district Ethics Committee. Investigations included subjective, kinematic, kinetic, electromyographic and bioenergetic assessments. The subjective assessment incorporated results from the Musculoskeletal Tumour Society Rating Scale (MSTS) and the Toronto Extremity Salvage Score (TESS). Overall impairment was found to be 83.33% according to results of the MSTS and overall disability was found to be 86.00% according to results of the TESS. Kinematic findings showed that limb salvage participants walked with reduced velocity (p < 0.01) and increased step asymmetry (p < 0.01). Patients exhibited an increase in plantarflexion during the loading response (p < 0.001) and during terminal stance (p < 0.05), and an increase in dorsiflexion during mid-stance (p < 0.001). Knee kinematics revealed reduced extension during the loading response (p < 0.001) and increased frontal plane excursion throughout the gait cycle (p < 0.01). Patients exhibited increased lateral lean during loading response at the trunk (p < 0.05). Kinetic findings revealed a reduction in the magnitude of vertical ground reaction force during the loading response (p < 0.001) and a reduction in the magnitude of the anterior/posterior ground reaction shear force during terminal stance (p = 0.01). Furthermore, the internal ankle plantarflexor moment in terminal stance was reduced (p < 0.001), all sagittal plane knee moments were reduced (p < 0.05) and the internal hip adductor moment in terminal stance was reduced (p < 0.01). Electromyographic findings found that the limb salvage participants activated their rectus femoris for a significantly prolonged period (p < 0.5) and exhibited increased bilateral co-contraction of their rectus femoris and medial hamstring muscles (p < 0.05) compared with control participants. Bioenergetic findings revealed that the limb salvage participants exhibited an increased energetic cost (p < 0.01) and consumption rate (p < 0.01). Moderate correlations were observed between electromyographic and bioenergetic findings. Multivariate methods suggested that muscle removal, knee extension strength and knee flexion range of motion were all significant predictors of locomotor function. Length of bone resection and time from surgery were not predictive of post-operative function. The findings supported the efficacy of a multifaceted gait analysis approach for the assessment of pathological function under research conditions. The combined approach, using multiple measurements, allowed determination of functional status following musculoskeletal alteration. This enabled identification of primary and secondary compensations and allowed recommendations for improved treatment and rehabilitation.

Introduction: Below knee amputation is the safest treatment for aggressive benign and malignant bone tumours of the distal tibia yielding good oncological and functional results. However, in selected patients where limb salvage is feasible and amputation unacceptable to the patient, limb salvage using a distal tibial replacement (DTR) can be considered. This study aims to present the oncological and functional results of the use of this treatment method in our unit. Patients &amp; Methods: A retrospective folder review was performed for all 10 patients who received a modular distal tibial replacement between 01/01/2005 and 31/01/2019 for a primary bone tumour either benign aggressive or malignant. Six were female and the mean age was 31 (1275) years. There were five patients with giant cell tumour of bone, four with osteosarcoma and one with a low-grade chondrosarcoma. The patients with osteosarcoma had neo-adjuvant chemotherapy before surgery. Function was assessed by the Musculoskeletal Tumor Society (MSTS) score. Results: There were six females and four males, with a mean age of 31 (12-75) years. Two patients had local recurrence treated with a BKA and one other patient died of metastases three years postoperatively. At a mean follow-up of three years, the remaining eight patients had a mean MSTS score of 83% (67–93%). There were no radiological signs of loosening, and no revision surgeries. Conclusion: Endoprosthetic replacement of the distal tibia for primary bone tumours can be a safe treatment option in very selected cases.

No description available.

Trotz der zunehmenden Bedeutung von freien Lappenplastiken stellen gefäßgestielte Suralis-Lappenplastiken weiterhin eine zuverlässige Methode zur Defektdeckung an der unteren Extremität dar. In der Arbeit werden 19 Fälle untersucht, bei denen eine Suralis-Lappenplastik durchgeführt wurde. Die Patientenzufriedenheit wird anhand funktioneller und ästhetischer Gesichtspunkte mittels eines standardisierten Fragebogens erfasst. Aus der ärztlichen Dokumentation werden notwendige Revisionseingriffe, stationäre und ambulante Behandlungszeiten, Nebenerkrankungen und die Erlössituation im DRG-System ausgewertet. Zudem wird im Rahmen einer anatomischen Studie an einem Leichenpräparat ein Suralis-Lappen gehoben und eine Fotodokumentation angefertigt.:1. Einleitung 2. Grundlagen 3. Material und Methoden 4. Ergebnisse 5. Diskussion 6. Zusammenfassung 7. Literaturverzeichnis 8. Anhang / Although the increasing meaning of free flaps the pedicled sural flap is a save method of covering defect wounds on lower limbs. In this report 19 cases of sural flap coverage are examined. The level of satisfaction of patients is measured by functional and aesthetic aspects using a standardised survey. Number of necessary revision operations, time of treatment, side diseases, and DRG based profit is determinded by the medical documentation. Furthermore an anatomic study is done showing the surgical raising of a sural flap.:1. Einleitung 2. Grundlagen 3. Material und Methoden 4. Ergebnisse 5. Diskussion 6. Zusammenfassung 7. Literaturverzeichnis 8. Anhang

Context. One of the most controversial subjects in anaesthesia today is whether or not neuraxial anaesthesia is more efficient to general anaesthesia in high-risk patients undergoing noncardiac surgery. The cumulative results showed that the incidence of postoperative cardiovascular morbidity and mortality is similar, regardless of type of the anaesthesia. So, is relevant to answer the search question: what is the efficiency of the neuraxial anaesthesia compared with general anaesthesia for lower-limbs revascularization in elderly? Objective. It is to determine the efficiency of the neuraxial anaestheisa versus general anaesthesia for lower-limbs revascularization in elderly. Hypothesis. The hypothesis is that the neuraxial anaestesia is more efficient (OR 0.67) than general anaesthesia for lower-limbs revascularization in elderly. Design. Systematic review with meta-analyse of the original articles of the randomized controlled trials. Setting. Federal University of Alagoas, Maceió, AL. Sample. Original articles of the randomized controlled trials that compared two anaesthetic technique (neuraxial anaesthesia vs. general anaesthesia) in elderly submitted to lower-limbs revascularization surgery. The information was accessed from EMBASE, LILACS, MEDLINE, CINHAL and ISI WEB OF SCIENCE. Main outcomes. Primary outcomes: Mortality, cerebral infarction, myocardial infarction, paralysis and postoperative lower limb amputation rate. Secondary outcomes: Duration of hospital stay, postoperative cognitive dysfunction, postoperative wound infection, other postoperative infections, neuraxial haematoma and complications in the anaesthetic recovery room. Complementary data: internal validity, external validity and statistical analyze. Statistical methods. For data analysis the odds ratio were used in the randon effect model with corresponding 95% confidence interval. / Contexto. A controvérsia atual é saber se a anestesia neuroaxial é mais eficiente do que a anestesia geral em pacientes de alto risco submetidos à cirurgia não cardíaca. Os resultados acumulados mostram que a incidência pós-operatória de mortalidade e morbidade cardiovascular é similar independentemente da técnica anestésica. Assim, é relevante responder a pergunta de pesquisa: qual a eficiência da anestesia neuroaxial comparada à anestesia geral para a revascularização dos membros inferiores em idosos? Objetivo. Determinar a eficiência da anestesia neuroaxial comparada à anestesia geral para a revascularização dos membros inferiores em idosos. Hipótese. A hipótese é que a anestesia neuroaxial é mais eficiente (OR 0,67) quando comparada à anestesia geral para a revascularização de membros inferiores em idosos. Tipo de estudo. Revisão sistemática com metanálise de artigos originais de ensaios clínicos aleatórios. Local. Universidade Federal de Alagoas, Maceió, AL. Amostra. Artigos originais de ensaios clínicos aleatórios que comparam duas técnicas anestésicas (anestesia neuroaxial vs. anestesia geral) em idosos submetidos à cirurgia de revascularização dos membros inferiores. Fontes de informação utilizadas: EMBASE, LILACS, MEDLINE, CINHAL e ISI WEB OF SCIENCE. Variáveis. Variáveis primárias: Mortalidade, infarto cerebral, infarto cardíaco, paralisia muscular e taxa pós-operatória de amputação de membro inferior. Variáveis secundárias: Tempo de duração da internação hospitalar, disfunção cognitiva pós-operatória, infecção pós-operatória, outras infecções pósoperatórias, hematoma neuroaxial e complicações na sala de recuperação pósanestésica. Dados complementares: itens da validade interna, itens da validade externa e análise estatística. Método estatístico. A metanálise foi apresentada com o cálculo das variáveis realizado pela odds ratio no modelo de efeito randômico, com respectivo intervalo de confiança de 95%.

Indiana University-Purdue University Indianapolis (IUPUI) / Peripheral arterial disease is caused by plaque buildup in the peripheral arteries. Standard treatments are available when the blockage is proximal and focal, however when distal and diffuse the same type of the treatment options are not beneficial due to the diseased locations. Restoration of blood flow and further salvaging of the limb in these patients can occur in a retrograde manner through the venous system, called retroperfusion or arteriovenous reversal. Retroperfusion has been explored over the last century, where early side to side artery to venous connections had issues with valve competency prohibiting distal flows, edema buildup, and heart failure. However, more recent clinical studies create a bypass to a foot vein to ensure distal flows, and though the results have been promising, it requires a lengthy invasive procedure. It is our belief that the concerns of both retroperfusion approaches can be overcome in a minimally invasive/catheter based approach in which the catheter is engineered to a specific resistance that avoids edema and the perfusion location allows for valves to be passable and flow to reach distally. In this approach, the pressure flow relations were characterized in the retroperfused venous system in ex-vivo canine legs to locate the optimal perfusion location followed by in-vivo validation of canines. Six canines were acutely injured for 1-3 hours by surgical ligation of the terminal aorta and both external iliac arteries. Retroperfusion was successfully performed on five of the dogs at the venous popliteal bifurcation for approximately one hour, where flow rates at peak pressures reached near half of forward flow (37±3 vs. 84±27ml/min) and from which the slope of the P/F curves displayed a retro venous vasculature resistance that was used to calculate the optimal catheter resistance. To assess differences in regional perfusion, microspheres were passed during retroperfusion and compared to baseline microspheres passed arterially prior to occlusion in which the ratio of retroperfusion and forward perfusion levels were near the ratio of reversed and forward venous flow (0.44) throughout the limb. Decreases in critical metabolites during injury trended towards normal levels post-retroperfusion. By identifying the popliteal bifurication as a perfusion site to restore blood flow in the entirety of the distal ischemic limb, showing reversal of injury, and knowing what catheter resistances to target for further chronic studies, steps towards controlled retroperfusion and thus more efficient treatment options can be made for severe PAD patients.