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Since ancient times, the aim of orthopedic surgery has been to correct limb and joint deformities, including those resulting from central nervous system lesions. Recent developments in the treatment of spasticity have led to changes in concepts and management strategies. The increase in life expectancy has increased the functional needs of patients. Orthopedic surgery, along with treatments for spasticity, improves the functional capacity of patients with neuro-orthopaedic disorders, improving their autonomy. In this paper, we describe key moments in the history of orthopedic surgery regarding the treatment of patients with central nervous system lesions, from poliomyelitis to stroke-related hemiplegia, from the limbs to the spine, and from contractures to heterotopic ossification. A synthesis of the current surgical techniques is then provided, and the importance of multidisciplinary evaluation and management is highlighted, along with indications for medical, rehabilitation and surgical treatments and their combinations. We explain why it is essential to consider patients' expectations and to set achievable goals, particularly before surgery, which is by nature irreversible. More recently, specialized surgical teams have begun to favor the use of soft-tissue techniques over bony and joint procedures, except for spinal disorders. We highlight that orthopedic surgery is no longer the end-point of treatment. For example, lengthening a contractured muscle improves the balance around a joint, improving mobility and stability but may be only part of the problem. Further medical treatment and rehabilitation, or additional surgery, are often necessary to continue to improve the function of the limb. Despite the recognized effectiveness of orthopedic surgery for neuro-orthopedic disorders, few studies have formally evaluated them. Hence, there is a need for research to provide evidence to support orthopedic surgery for treating neuro-orthopedic disorders.

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Review of the literature.It is widely believed that the timing of surgery and the size of the initial Neurological Heterotopic Ossification (NHO) affect the recurrence risk of NHO after SCI. A large number of studies were published in the 80s and the 90s, mostly of poor quality despite the fact that they were carried out by experienced surgical teams. The aim of this study was to suggest recommendations relating to the timing of excision of heterotopic ossification after SCI following the analysis of a recent review of the literature.France.A systematic literature search was performed in the PubMed Embase from January 2002 until June 2014 using the MESH headings 'spinal cord injury', 'paraplegia', 'heterotopic ossification' and 'surgery'. Results were compared with results from epidemiological studies based on the BANKHO database (patients who underwent surgery for troublesome HO after central neurological system (CNS) lesions in our center (357 patients, 539 surgeries)).Few studies were found in the literature, results were sometimes contradictory and practices heterogeneous. Results from the BANKHO database showed that troublesome recurrence of NHO was not associated with 'early' surgery (before 6 months), and no association was found between recurrence and the size of the NHO around the joint (Brooker status).We suggest that surgical excision of the NHO should be carried out when it begins to be troublesome, as soon as comorbid factors are under control and the HO is sufficiently constituted for excision.

Background Korian is a private group specializing in medical accommodations for elderly and dependent people. A professional data warehouse (DWH) established in 2010 hosts all of the residents’ data. Inside this information system (IS), clinical narratives (CNs) were used only by medical staff as a residents’ care linking tool. The objective of this study was to show that, through qualitative and quantitative textual analysis of a relatively small physiotherapy and well-defined CN sample, it was possible to build a physiotherapy corpus and, through this process, generate a new body of knowledge by adding relevant information to describe the residents’ care and lives. Methods Meaningful words were extracted through Standard Query Language (SQL) with the LIKE function and wildcards to perform pattern matching, followed by text mining and a word cloud using R® packages. Another step involved principal components and multiple correspondence analyses, plus clustering on the same residents’ sample as well as on other health data using a health model measuring the residents’ care level needs. Results By combining these techniques, physiotherapy treatments could be characterized by a list of constructed keywords, and the residents’ health characteristics were built. Feeding defects or health outlier groups could be detected, physiotherapy residents’ data and their health data were matched, and differences in health situations showed qualitative and quantitative differences in physiotherapy narratives. Conclusions This textual experiment using a textual process in two stages showed that text mining and data mining techniques provide convenient tools to improve residents’ health and quality of care by adding new, simple, useable data to the electronic health record (EHR). When used with a normalized physiotherapy problem list, text mining through information extraction (IE), named entity recognition (NER) and data mining (DM) can provide a real advantage to describe health care, adding new medical material and helping to integrate the EHR system into the health staff work environment. Electronic supplementary material The online version of this article (doi:10.1186/s12911-017-0519-0) contains supplementary material, which is available to authorized users.

Les deformations orthopediques des membres superieurs ou inferieurs sont frequemment observees au cours des pathologies neurologiques vasculaires, posttraumatiques, degeneratives. Quelle qu’en soit l’etiologie, elles peuvent entrainer des lesions cutanees par maceration, relief osseux anormal ou modification des points d’appui au lit ou au fauteuil. La prise en charge de ces lesions cutanees reste delicate et doit imperativement passer par le diagnostic de ces deformations, l’identification de leurs causes, et la correction de celles-ci. Le but de ce travail est de faire une revue des differentes deformations orthopediques pouvant etre retrouvees chez le patient neurologique et de proposer une strategie de diagnostic et d’elaboration therapeutique adaptee au terrain particulier de ces patients. La prise en charge precoce de ces deformations orthopediques est recommandee afin d’eviter les lesions cutanees surinfectees qui constituent une epine irritative majorant les deformations, les rendant plus difficiles a traiter, et entrainant un veritable cercle vicieux.

Botulinum Toxin A has been the main treatment for spasticity since the beginning of the 1990s. Surprisingly, there is still no consensus regarding injection parameters or, importantly, how to determine which muscles to target to improve specific functions. The aim of this study was to develop a systematic approach to determine this, using the example of the arm flexion pattern. We first determined anatomical landmarks for selective motor block of the brachialis nerve, using 20 forearms from 10 fresh cadavers in Ecole Europeenne de Chirurgie and a university-based dissection centre, Paris, France. We then carried out selective blocks of the motor nerves to the brachialis, brachioradialis and biceps brachii in patients with stroke with an arm flexion pattern, in a University Rehabilitation Hospital, Garches, France. We measured: the resting angle of the elbow angle in standing (manual goniometer), active and passive range of extension, and spasticity using the Held and Tardieu and the Modified Ashworth scales. Range of passive elbow extension was also measured with the shoulder in 90° of flexion. The resting angle of the elbow in standing decreased by 35.0° (from 87.6 ± 23.7 to 52.6 ± 24.2°) with inhibition of brachialis, by a further 3.9° (from 52.6 ± 24.2 to 48.7 ± 23.7°) with inhibition of brachioradialis and a further 14.5° (from 48.7 ± 23.7to 34.2 ± 20.7°) with inhibition of biceps brachii. These results were consistent with the clinical evaluation of passive elbow range of motion with the shoulder at 90°. Sequential blocking of the nerves to the three main elbow flexors revealed that the muscle that limited elbow extension the most, was brachialis. This muscle should be the main target to improve the arm flexion pattern. These results show that it is important not simply to inject the most superficial or powerful muscles to treat a spastic deformity. A comprehensive assessment is required. The strategy proposed in this paper should increase the effectiveness of botulinum toxin injections by ensuring that the relevant muscles are targeted.

Le positionnement au fauteuil de la personne âgee dependante est une preoccupation majeure de l’equipe soignante pluridisciplinaire et un defi quotidien complexe a relever pour l’ergotherapeute. Pour les personnes âgees presentant des troubles posturaux majeurs (retractions, hypertonie), l’ergotherapeute est amene a travailler en lien avec des medecins MPR, chirurgiens pratiquant des injections de toxine ou de phenol ainsi qu’avec des professionnels du positionnement, notamment des orthoprothesistes realisant des corsets-sieges. Ce partenariat est parfois la seule maniere de repondre au contrat de positionnement propose au patient apres la necessaire evaluation benefice/risque. Cependant, des limites individuelles (telles que le vecu douloureux et traumatisant de certains patients) et institutionnelles (telles que le manque de formation du personnel soignant) restent encore des obstacles a la pleine realisation de tels projets.

Objectif Elaborer une synthese des pratiques professionnelles concernant la prise en charge des fractures recentes des membres inferieurs chez le patient poliomyelitique adulte.

Les deformations neuro-orthopediques des hanches sont frequentes chez les patients spastiques et realisent une multitude de tableaux cliniques. Dans tous les cas, la part de la spasticite, des retractions, des raideurs, des deficits musculaires, doit etre precisee afin de definir le programme medicochirurgical. Celui-ci est adapte en fonction des objectifs definis contractuellement avec le patient et sa famille. L’association de plusieurs deformations pose la question de la hierarchie des gestes (intervention proximale ou distale) et chronologique (en un ou plusieurs temps).

Objective International and national guidelines recommend an annual funduscopic examination for all diabetic patients, but such annual fundus examinations are not sufficiently performed in France. Non-mydriatic fundus photography is a valid method of evaluation for diabetic retinopathy (DR) and a viable alternative to ophthalmoscopy. After two pilot studies demonstrated the feasibility of telemedical screening for diabetic retinopathy in both hospital and primary-care settings, we developed a regional telemedical network, OPHDIAT © , designed to facilitate access to regular annual evaluations of patients with diabetes while saving medical time. Materials and methods OPHDIAT © comprises peripheral screening centres equipped with non-mydriatic cameras, where fundus photographs are taken by technicians linked by telemedicine to a reference centre, where ophthalmologists grade the images. Currently in the Ile-de-France region, 16 screening centres are linked through a central server to an ophthalmologic reading centre and includes 11 centres located in the diabetes departments of 11 hospitals, one diabetic retinopathy screening centre located in northern Paris, three in healthcare centres and one in a prison. Results During the 28-month evaluation period, 15,307 DR screening examinations were performed. Retinal photographs of at least one eye could not be graded in 1332 patients (9.7%) and diabetic retinopathy was detected in 3350 patients (23.4%). After the screening examination, 3478 patients (25.2%) were referred to an ophthalmologist for either DR, cataract and/or non-gradable photographs. Conclusion Fundus photography combined with telemedicine has the potential to improve the regular annual evaluation for diabetic retinopathy. The organization of the network around a central reading centre serves to guarantee quality control.

La chirurgie est une alternative souvent incontournable dans le traitement des retractions musculaires chez les patients ayant souffert de lesions du systeme nerveux central. De nombreuses possibilites s’offrent au chirurgien: geste sur le tendon (longueur ou transfert), os, articulation… Les strategies operatoires (voie d’abord, un ou plusieurs temps…) se discutent au cas par cas. Les indications tiennent compte des eventuelles possibilites de recuperations neurologiques ou fonctionnelles (pas d’affaiblissement de muscles transferables, limiter les gestes definitifs). Les difficultes resident essentiellement dans l’evaluation pre-operatoire, afin de faire la part des choses entre spasticite et retraction et de determiner l’eventuelle activite des muscles antagonistes. Le contrat pre-operatoire realise avec le patient depend de cette evaluation qui gagne a etre multidisciplinaire.

Neurogenic myositis ossificans is a disabling condition affecting the large joints of patients with severe post-traumatic impairment of the central nervous system. It can result in ankylosis of the joint and vascular or neural compression. Surgery may be hazardous with potential haemorrhage, neurovascular injury, iatrogenic fracture and osteochondral injury. We undertook pre-operative volumetric CT assessment of 45 ankylosed hips with neurogenic myositis ossificans which required surgery. Helical CT with intravenous contrast, combined with two- and three-dimensional surface reconstructions, was the only pre-operative imaging procedure. This gave good differentiation of the heterotopic bone from the adjacent vessels. We established that early surgery, within 24 months of injury, was neither complicated by peri-operative fracture nor by the early recurrence of neurogenic myositis ossificans. Surgical delay was associated with a loss of joint space and a greater degree of bone demineralisation. Enhanced volumetric CT is an excellent method for the pre-operative assessment of neurogenic myositis ossificans and correlates well with the operative findings.

La prise en charge des hypertonies neurologiques chez les personnes tres âgees n’a qu’exceptionnellement ete etudiee dans la litterature. La toxine botulique A est le traitement de premiere intention mais a des limites de cout liees a la mise en place effective des filieres de soins et aux troubles comportementaux des patients durant les injections. La phenolisation nerveuse a une place de choix lorsque les nerfs a contingent moteur sont en cause: faible cout, realisation en ambulatoire, geste parfois unique. La phenolisation intramusculaire doit etre evaluee et precisee, car elle est actuellement peu realisee et ne fait l’objet d’aucun consensus.

Summary Twenty patients were operated upon for heterotopic ossification around the elbow of neurogenic origin following intra-cranial trauma between 1993 and 1997. They did not receive any diphosphonates or radiotherapy. Pre-operative evaluation included a CT scan with enhancement using a dye injected intravenously and 3D reconstruction. Surgery was indicated in the presence of a clinical deficit in mobility or signs (clinical or electrical) of nerve compression. The average delay between the accident and the surgery was 34 months (5 months to 9 years). Associated procedures included lengthening of the brachialis (4 cases), lengthening of the triceps tendon (4 cases) and an anterior capsulotomy in 3 cases. 24 elbows were reviewed with an average follow-up period of 18 months (6 months to 4 years). In 58% of the cases, the result was very good (gain in mobility > 70%) while in the remaining 42% of cases, the improvement was between 40% and 70%. This study confirms the possibility of obtaining good results by excision of the masses of heterotopic ossification of neurogenic origin around the elbow before 1 year after the accident without the necessity of complementary treatment.

Les deformations orthopediques observees apres lesion neurologique centrale sont principalement musculotendineuses. Devant une limitation de mobilite articulaire, il faut cependant eliminer une cause «articulaire» et realiser une radiographie de l’articulation concernee afin d’eliminer une para-osteo-arthropathie (POA) si le patient est traumatise crânien ou blesse medullaire. La realisation de blocs neuromoteurs anesthesiques selectifs permettra de determiner le(s) muscle(s) responsable(s) de la deformation, leur caractere spastique et/ou retracte, l’existence et la qualite des muscles antagonistes et de preciser avec le patient la strategie therapeutique et un contrat d’objectif clair et realiste.

La spasticite focale ou diffuse est une des consequences d’une lesion du systeme nerveux central. Son traitement peut etre physique (kinesitherapie, cryotherapie), medicamenteux par voie generale (baclofene, dantrolene, tizanidine). La toxine botulinique en injection intramusculaire est actuellement le traitement de premiere intention dans le cadre d’une spasticite focale. Dans le cas des hypertonies diffuses des membres inferieurs, le baclofene intrathecal peut etre une alternative therapeutique.

Les blocs anesthesiques moteurs sont un outil precieux dans l’evaluation des deformations articulaires chez les patients presentant une lesion du systeme nerveux central. La strategie la mieux codifiee est celle concernant le pied varus equin. En effet, l’examen clinique associe aux resultats des blocs-moteurs anesthesiques permet de faire la part entre hypertonie et retraction afin de proposer au patient une strategie therapeutique. L’objectif est souvent un « pied a plat et stable » avec ou sans technique adjuvante, orthese ou aide technique. Les plaintes du patient et le contrat passe doivent rester les elements incontournables de la prise en charge.

Using two new cases and 70 case reports in the literature as a starting point, the authors focus on the Weismann-Netter-Stuhl syndrome. Weismann-Netter and Stuhl reported the first cases of tibioperoneal diaphyseal toxopachyosteosis in 1954. This syndrome is defined as an anomaly of the diaphyseal part of both tibiae and fibulae with posterior cortical thickening and anterior-posterior bowing. This anomaly is usually bilateral and symmetrical and patients are short. The thickening of the fibula is true tibialisation and is the main feature and the only feature confirming diagnosis. Routine laboratory investigations showed no abnormalities. The authors specify the limits encountered in classifying this anomaly and discuss the degree to which this anomaly is an entity unto itself when compared with rickets sequelae.

Interactions of physical, emotional, cognitive and behavioural impairments after severe closed head injury (CHI) remain poorly understood. A 47-year-old man was referred to our department 13 months after a severe CHI. He demonstrated severe left hemiplegia and disabling orthopaedic complications (left hip infectious arthritis, after surgical treatment for heterotopic ossification). His hip was blocked and extremely painful. He was totally dependent for daily-life activities (Functional Independence Measure (FIM) score = 18). Moreover he exhibited severe cognitive and behavioural troubles, which had been stable for many months beforehand, e.g. complete disorientation for time and place, major memory disorders, agitation, anxiety, depression, irritability, disinhibition, aggressiveness and lack of initiative. Pain disappeared within a few weeks after treatment. Progressively, functional improvement occurred (sitting position, transfers, walking between parallel bars). The FIM score increased to 63. Aggressiveness, irritability and agitation disappeared. Surprisingly, neuropsychological assessment demonstrated parallel improvement of cognitive functions, especially in regard to orientation, and to a lesser degree attention and memory. Such an observation should encourage use of active treatment of physical disabilities, even in patients presenting with an apparently poor cognitive prognosis at a late stage of severe CHI.