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PubMed1977

Fragmentation of the distal pole of the patella in spastic cerebral palsy.

Of eighty-five consecutive patients, thirteen to twenty years old, with spastic cerebral palsy involving one or both extremities (thirty-five patients seen at one institution and fifty, at another), four had roentgenographic evidence of fragmentation of the distal pole of the patella. In addition, three other patients with six spastic lower extremities, four of them with patellar fragmentation, were also included. In these seven patients, there were nine knees with patellar fragmentation, twelve knees with patella alta, nine with a flexion contracture, five that were painful, and four with changes in the tibial tubercle resembling those found in Osgood-Schlatter disease. Excessive tension in the quadriceps mechanism, usually in the presence of a flexion contracture, appeared to cause the lesions. Four of the fragmented patellae healed after hamstring release and correction of the flexion deformity.

Achilles Tendon↗
PubMed1978

Knee muscular moment, tendon tension force and EMG during a vigorous movement in man.

With injuries to the components of the extensor apparatus of the knee as a background, it is interesting to investigate the magnitude of forces acting on these components, i.e. m. quadriceps femoris, the quadriceps tendon, patella, lig. patellae and tuberositas tibiae, during a vigorous but physiological movement. By means of the dynamic laws of mechanics the muscular moment of force with respect to the bilateral knee axis during kicking was calculated in 6 normal subjects. It was found that the maximum extending muscular moment in the knee occurs very early in the movement, when the initial flexion changes into extension, and thus long before the ball is hit. The peak of quadriceps EMG activity coincides with maximum moment. The EMG peak of the antagonistically acting hamstrings comes later, nearer to when the ball is struck. The greatest extending muscular moment obtained during the swing phase of kicking was surprisingly high, 260 Nm, corresponding to a tension force in the patellar tendon of 5200 N or about 7 times body weight. These values are discussed in relation to tendon strength.

Adult↗
PubMed1990

[Pindolol-induced rhabdomyolysis in sarcoid myopathy].

A 72-year-old man suddenly developed severe muscle weakness following the treatment with pindolol (Calvisken) for three days. Neurological examination on admission disclosed marked proximal muscle weakness with absent deep tendon reflexes. Laboratory data showed significant increase of serum CK, aldolase and myoglobin. Electromyography revealed both neurogenic and myogenic changes in all muscle tested. Skeletal muscle CT showed patchy low density areas in muscles of thigh and leg, especially in the hamstrings. Femoral muscle biopsy demonstrated a granulomatous nodule with multinucleated giant cells in the degenerated muscle fibers showing small-grouped atrophy. By Mb-PAP staining, Mb-negative fibers were randomly distributed among normally stained ones. Leu 1, 3a, 4, HLA-DR positive cells were found adjacent to the granuloma by immunoperoxidase staining. After immediate withdrawal of pindolol and treatment with steroid, he recovered muscle strength and enzyme activities were normalized in a week. Beta blockers have been known to induce muscle cramps or pain and moderate elevation of serum muscle enzymes. However, severe muscle weakness with highly elevated enzyme activities leading to rhabdomyolysis as noticed in the present case was rarely reported in the literature. Underlying sarcoid myopathy might be suspected to exaggerate this unusual case of pindolol-induced rhabdomyolysis. A careful use of pindolol is emphasized.

Aged↗
PubMed1990

[Long-term follow up of anterior cruciate ligament reconstruction using autologous tendon graft augmented with alloplasty (Kennedy LAD)].

From October 1983 to January 1990 in 493 patients 499 injured anterior cruciate ligaments were reconstructed by a composite tendon graft. The autogenous graft, semitendinosus tendon or quadriceps-patella periost-patellar tendon, both anatomically attached distally, was augmented with the polypropylene braid (Kennedy LAD). In the period of January to November 1984 in 81 patients anterior cruciate ligament replacement was performed. A retrospective 2-years follow-up in 72 patients and a second 5-years follow-up in 67 of those 72 patients was possible. There were 38 patients with an acute rupture and 34 patients with chronic instability. Clinical and instrumented laxity revealed a mean displacement difference of not more than 3 mm in 84% of the patients in comparison of the involved with the normal knee at the 2-years and 5-years follow-up. 80% of strength analyses showed a physiological balance of quadriceps and hamstrings in the 5-years follow-up. In the 2-years follow-up only 41% of patients practiced former sports activities again, whereas in the 5-years follow-up 80% of the patients were able to join former sports. 80 to 100 points of Lysholm score demonstrating good to very good results were reached in 91% of the patients. Especially cartilage damages in cases of chronic instabilities worsened the results mentioned by the patients.

Adult↗
PubMedDate not supplied

Physiologic loading of the anterior cruciate ligament does not activate quadriceps or hamstrings in the anesthetized cat.

We attempted to elicit quadriceps and hamstring electromyographic responses in seven chloralose-anesthetized cats by loading the ACL with controlled anterior displacement of the tibia on the femur using rigid fixation and an MTS testing machine. We did not detect reflex activity in the quadriceps or hamstring muscles of any of the cats in response to anterior tibial displacements of up to 4 mm, with rise times ranging from 1.0 to 0.1 seconds. In four of the cats we loaded the ACL using a wire loop. Loads of up to 125 N (4 to 5 times body weight) produced no reflex activity in any of the four animals, although we consistently observed monosynaptic reflex responses to tendon taps. Whole nerve recordings from the posterior articular nerve revealed substantial activity from afferents in response to tugging on the ACL, although we could not differentiate receptors in the ACL from those in other periarticular tissues. Thus, while traction on the intact ACL causes signals in the afferent nerves, those signals are not translated into direct monosynaptic reflexes.

Animals↗
PubMed1990

Isolated avulsion of the biceps femoris insertion. A case report.

The clinical, roentgenographic, and operative findings of an isolated biceps femoris avulsion in a 21-year-old man demonstrated the significance of the static stabilizers about the knee, menisci, and articular cartilage. Examination of the dynamic structures about the knee, however, may present a diagnostic problem. A systematic examination of the musculature (hamstrings, quadriceps, and patellofemoral mechanism) should be included in the evaluation of every acute knee injury. Special attention should be given to the surface anatomy as well as function of the knee.

Adult↗
PubMed1990

Nonoperative treatment of acute knee ligament injuries. A review with special reference to indications and methods.

Nonoperative treatment has received little attention in the numerous scientific reports on knee ligament injuries. Great controversy still exists concerning the proper treatment of a knee with a ruptured ligament, especially the anterior cruciate ligament. However, according to the studies of the authors and an extensive review of the literature the indications for conservative management can be established to be all grade I and II sprains (partial tears) of knee ligaments as well as an isolated grade III sprain (complete tear) of the posterior cruciate ligament. In addition, an isolated complete rupture of an anterior cruciate, or medial or lateral collateral ligament may be treated nonoperatively in an older sedentary person. Other injuries obviously call for an operative approach at the acute stage. Nonoperative therapy protocols must be based on the knowledge of the biological phenomenon occurring during connective tissue healing process. In the first phase of ligament healing the injured knee needs 2 to 3 weeks immobilisation for undisturbed fibroblast invasion and proliferation of collagen fibres. This is achieved by immobilising the knee in a rehabilitative knee brace locked in 40 to 45 degrees of flexion. Thereafter, a gradually increasing controlled mobilisation is allowed in the brace to avoid the deleterious effects of immobilisation to cartilage, bone, muscles, tendons and ligaments, and to enhance the orientation of collagen fibres to the stress lines of the healing ligament. After 4 to 8 weeks the goal for rehabilitation is rapid and full recovery to work and sports. A functional knee brace may be used at this phase to give extra protection before final strengthening of the injured ligament. During the mobilisation and muscle training of the therapy protocol various specific techniques can be used for strengthening of the hamstring and quadriceps muscles, including isometric, isotonic, isokinetic and eccentric exercises with or without resistive equipments. In addition, electrical stimulation may help prevent muscle wasting due to immobilisation, and continuous passive motion may be used to correct persistent extension or flexion deficit. Normally, jogging is allowed approximately 3 to 6 months after the injury, and an athlete is generally able to return to full activity and competitive sports after 6 to 12 months. Quite frequently the whole question of successful rehabilitation after a knee ligamentous injury is more motivational rather than methodological and is thus often independent of attending physician's or physiotherapist's skill or will. Therefore, one of the most important things during rehabilitation is to motivate and encourage the patient for longstanding, intensive work.

Biomechanical Phenomena↗
PubMed1979

Management of severe spondylolisthesis in children and adolescents.

Forty-three patients with a fifth lumbar-first sacral spondylolisthesis of 50 per cent or greater were reviewed. Four had been treated non-operatively; eleven, by arthrodesis; eighteen, by decompression and arthrodesis; and ten, by reduction and arthrodesis. The angle of slipping (measurement of the kyphotic relationship of the fifth lumbar to the first sacral vertebra) was found to be as important a measurement as the percentage of slipping in measuring instability and progression of slipping. Hamstring tightness did not correlate with neural deficit. Arthrodesis alone, even in the presence of minor neural deficits, tight hamstrings, or both, gave relief of pain and resolution of neural deficits and tight hamstrings. Our experience with a limited number of patients suggests that management by postoperative extension casts may achieve a significant reduction in percentage of slipping and in angle of slipping. Progression of the spondylolisthesis may occur following a solid arthrodesis.

Achilles Tendon↗
PubMedDate not supplied

Anterior cruciate ligament injury: evaluation of intraarticular reconstruction of acute tears without repair. Two to seven year followup of 155 athletes.

To evaluate the effectiveness of our treatment regimen, we retrospectively studied the surgically treated knees of 155 athletes, aged 15 to 42 years, who had sustained acute ACL tears. All were treated with ligament excision and intraarticular bone-patellar tendon-bone reconstruction followed by early motion with emphasis on full extension. The follow-up period ranged from 2 to 7 years. Of the 155 patients, 140 were available for final followup at a minimum of 2 years after reconstruction. The patients were evaluated by objective measures (KT-1000, Cybex, Lachman test, range of motion, and postoperative competition level) and subjective assessment scores (pain, swelling, stability, activity level, walking, stair climbing, running, jumping, or twisting). The subjective scores were tabulated for stability level, total score, and activity level. After the patients achieved full range of motion, the KT-1000 measurements at a 20 pound force revealed an average difference of 1.3 mm between the injured and noninjured knees. All but 3 of the 140 patients had a firm endpoint on the Lachman test, and the Cybex tests showed a mean hamstring strength of 98% and mean quadriceps strength of 90%. Sixty of the 69 varsity athletes who were eligible to play returned to preinjury competition level the following season. One had reconstruction failure and eight chose not to continue competition for academic reasons. The questionnaire score average was 92.7 (maximum, 100 points, normal athletic knee score 93.5). We concluded that the surgical procedure, with emphasis on early full extension postoperatively, achieved excellent results and provided a stable knee.

Adolescent↗
PubMed1990

[Analysis of the shear force exerted on the tibia during standing on bilateral legs with knee flexion].

Biomechanical analysis of the two-dimensional models composed of roentgenographic pictures and electromyographic analysis about the shear force (Fs) exerted on tibia during standing on bilateral legs was conducted in 21 young adult males. The simultaneous contraction of the quadriceps and hamstrings was observed in all electromyograms (EMGs). Amplitude observed on EMGs of the hamstrings increased as the trunk flexion angle increased. The calculated average values of Fs were negative at every knee flexion angle; Negative value means posteriorly directed force. As the trunk flexion angle increased, posterior drawer force increased at knee flexion angles of 30 degrees and 60 degrees. The simultaneous contraction of the quadriceps and the hamstrings was considered to represent the main factor that influenced these results. The standing on bilateral legs with knee and trunk flexion was considered to be applicable in the early stages after anterior cruciate ligament reconstruction.

Adult↗
PubMed1976

The treatment of intoed gait in spina bifida patients by lateral transfer of the medial hamstrings.

The operation of lateral transfer of the medial hamstring muscles is described. Its applicating in the management of intoed gait in spina bifida is discussed, and the results of eight such operations, performed on four children, are recorded. The operation was effective in correcting the intoed gait in all; however, there was no activity in the transferred muscles in one child.

Child, Preschool↗
PubMed1992

The management of decubitus ulcers by musculocutaneous flaps: a five-year experience.

Large decubitus ulcers can be treated by using many methods, including musculocutaneous flaps. Musculocutaneous flaps provide reliable, well-vascularized cover and often can be revised in patients with secondary recurrence. We have treated 30 patients with large decubitus ulcers during a 5-year period by using musculocutaneous advancement flaps of the gluteus maximus, the hamstring muscle, and the tensor fasciae latae. There were two complications treated by debridement with flap advancement in 1 patient and the use of another flap in the second patient. Four patients developed a recurrent ulcer, which was treated by reelevation and advancement of the original flap in all patients. The general management and overall results are presented.

Buttocks↗
PubMedDate not supplied

Distal hamstring elongation in the management of spastic cerebral palsy.

Forty-nine children with spastic cerebral palsy treated by distal hamstring elongation and followed for an average of 4.4 years were reviewed. The aim of the operation was to release hamstring tightness to improve the patients' level of function and efficiency and the cosmetic appearance of their gait. Forty patients had significant improvement in gait pattern, and 18 had improved motor function. Complications included transient stiff-legged gait and exaggerated lumbar lordosis. One patient with spastic quadriceps had 15 degrees of persistent genu recurvatum.

Adolescent↗
PubMed1979

Lateral hamstring transfer and gait improvement in the cerebral palsy patient.

A retrospective analysis of twenty-three spastic patients who underwent forty-three transfers of the semitendinosus muscle to the lateral intramuscular septum and of the semimembranosus muscle to the biceps is presented. Decreased knee-flexion deformity as well as improved walking function were achieved in 91 per cent. An unsatisfactory result was associated with complications of the procedure. Only one knee of the forty-three that were operated on showed late genu recurvatum. This procedure appears to be both effective and relatively free of late comlications.

Adolescent↗
PubMed1992

Effect of knee joint laxity on long-loop postural reflexes: evidence for a human capsular-hamstring reflex.

The onset latency and discharge amplitude of preprogrammed postural responses were evaluated in order to determine if the structure of synergistic activation could be altered by ligamentous laxity at the knee joint. Twelve subjects with unilateral and one subject with bilateral anterior cruciate ligament (ACL) insufficiency were tested while standing on a moveable platform. External balance perturbations (6 cm anterior or posterior horizontal displacements of the platform) were presented at velocities ranging from 15 to 35 cm/s. Perturbations were presented under the following experimental conditions: unilateral and bilateral stance, knees fully straight or flexed, and with ankle motion restricted or free. These stance, knee position, and ankle motion conditions were introduced to alter the stress transmitted to the knee joint during movement of the support surface. The automatic postural response was recorded from the tibialis anterior (T), quadriceps (Q), and medial hamstrings muscles (H) bilaterally. The normal response to an externally induced backward sway involved the automatic activation of T and Q at latencies of 80 ms and 90 ms respectively. Activation of the hamstrings in the non-injured extremity was not coupled with the postural response. Hamstrings are not typically involved in the correction posterior sway because H activation would tend to pull the center of mass further backwards. However, when the response in the ACL-deficient extremity was compared to the non-injured limb: (1) the automatic postural response in the ACL-deficient extremity was restructured to include hamstrings activation (100 ms latency), (2) H activation time was faster and less variable in the ACL-deficient limb, and (3) the ratio of H/Q discharge amplitude integrated over 100 ms and 200 ms from the onset of EMG activation showed a dominance of hamstring activity during unilateral stance on the lax limb. In addition, H/Q ratios integrated over 200 ms showed dominant hamstring activity in the ACL-deficient limb during bilateral stance. (4) Cross-limb comparisons showed greater normalized IEMG amplitudes for T, H, and Q during unilateral stance on the lax limb. These results suggest that a capsular-hamstring reflex is integrated into the existing structure of a preprogrammed postural synergy in order to compensate for ligamentous laxity. Furthermore, the generalized increase of response gain observed during perturbations of unilateral stance on the lax limb indicates that joint afference can modulate central programming to control localized joint hypermobility. A concept of postural control is discussed with respect to the capsular reflex, joint loading and displacement of the center of gravity.

Adolescent↗
PubMed1991

Changes in hip position modulate soleus H-reflex excitability in man.

The effects of hip flexion and extension on the ipsilateral soleus Hoffmann (H) reflex recruitment curve were studied in 11 healthy subjects. Hip flexion (50 degrees), but not hip extension (15-20 degrees), produced changes in the H-reflex. A maintained facilitation, peaking at intensities of stimulation producing a maximal H-reflex (Hmax), was observed in 6/18 sessions. Inhibition, peaking at intensities submaximal for Hmax, was seen in 7/18 sessions. In some of the latter experiments, there was also a facilitation at high intensities of stimulation (greater than Hmax). The remaining experiments were classified as showing no effect: 3 were unmodulated but 2 showed a facilitation at high intensities of stimulation (greater than Hmax). Since the knee was extended in the test position, a second series of experiments (n = 7) were carried out to determine the possible influence of stretch of the biarticular hamstrings muscle group on the soleus H-reflex by comparing the effects of hip flexion with the knee extended with those obtained when the knee was flexed, thereby relaxing the hamstrings. The results provided no evidence that the variability could be explained by differences in the relative degree of stretch on the hamstrings muscle group. There were, however, systematic variations in the shape of the corresponding control H-reflex recruitment curves between subjects: the mean slope of the rising limb of the recruitment curve was highest in those experiments showing an inhibition, intermediate in the ineffective experiments and lowest in those showing a maintained facilitation. These observations indicate that the reflex output studied was different in the three groups, possibly reflecting differences in the relative proportions of slow- and fast-twitch motor units contributing to the reflex response.

Achilles Tendon↗
PubMedDate not supplied

Hamstring tenotomies in cerebral palsy: long-term retrospective analysis.

One hundred seventeen cerebral palsy patients were followed for a mean of 3.4 years after undergoing hamstring tenotomy by proximal semimembranosus release in conjunction with distal semitendinosus and biceps femoris release. Range of motion was significantly improved 1 year after the operation and remained so for 4 years. Thirty percent of nonambulatory patients improved at least one level in activity, some at up to 12 years of age. Minor recurvatum was observed at 1 year but became nearly nonexistent after 3-5 years.

Activities of Daily Living↗