Decrease of Muscle Mass in Young Patients With Neuromuscular Disease:Assessment of Sarcopenia

Background@#Sarcopenia can be associated with the disease etiologies other than degenerative processes, such as neurologic disease including cerebral palsy, myelomeningocele, or Duchenne muscular dystrophy, even in children. Although the relationship between neurologic disease and scoliosis or ambulatory function is known, the mediators affecting scoliosis or gait function in these patients are unclear, an example might be sarcopenia. This study aimed to assess the degree of sarcopenia in young patients with neurologic diseases using computed tomography (CT), and analyze the correlation between sarcopenia and scoliosis or ambulatory function. @*Methods@#Pediatric and young adult patients (≤ 25 years old) who underwent whole-spine or lower-extremity CT were retrospectively included. From bilateral psoas muscle areas (PMAs) at the L3 level, the psoas muscle z-score (PMz) and psoas muscle index [PMI = PMA/(L3 height) 2 ] were calculated. The t-test, Fisher’s exact test, and logistic regression analyses were performed. @*Results@#A total of 121 patients (56 men, mean age 12.2 ± 3.7 years) were included with 79 neurologic and 42 non-neurologic diseases. Patients with neurologic diseases had lower PMz (P = 0.013) and PMI (P = 0.026) than patients without. In neurologic disease patients, severe scoliosis patients showed lower PMz (P < 0.001) and PMI (P = 0.001). Non-ambulatory patients (n = 42) showed lower BMI (β = 0.727, P < 0.001) and PMz (β = 0.547, P = 0.025). In non-ambulatory patients, patients with severe scoliosis also showed lower PMz (P < 0.001) and PMI (P = 0.004). @*Conclusion@#Patients with neurologic diseases could have sarcopenia even in young age.Psoas muscle volume was also associated with ambulatory function in these patients.Sarcopenia was more severe in severe scoliosis patients in the non-ambulatory subgroup.

Diagnosis and treatment of congenital scoliosis

Congenital scoliosis is caused by anomalies of the vertebra, such as hemivertebra or unsegmented bar, which result in asymmetric growth of the spine. The disruption of vertebra development during embryogenesis may be accompanied by other congenital multi-organ anomalies. The progression of the scoliotic curve may also hinder the development of other organs.Current Concepts: Hemivertebra excision and short spinal fusion have demonstrated favorable outcomes. However, the need for spinal growth and lung development has led to new treatment modalities. Growth-friendly surgeries, such as with a growing rod or vertical expandable rib-based distraction device, have demonstrated good results with curve correction while maintaining spinal growth. Although the outcome of conservative treatment for congenital scoliosis is questionable, casting may be effective as a “time-buying strategy” to delay the need for surgery.Discussion and Conclusion: It is essential to decide on a treatment plan considering the progression of the curve and growth of the spine and lungs through an individualized approach.

Pediatric Fractures around the Wrist

Fractures around the wrist are the third most common fracture among all pediatric fractures. Furthermore, distal radius fractures, a type of wrist fracture, are the most common fractures in children. Understanding pediatric fractures around the wrist is very important considering their prevalence. There is a specific belief that pediatric fractures can heal easily because of remodeling, but not all fractures can heal without proper treatment. Complications such as growth problems, nonunion can occur if the fracture is not treated properly. This paper reviewed recent articles about distal radius fractures, Galeazzi-equivalent fractures, and carpal bone fractures, including scaphoid fractures in children and adolescents. Successful treatment can be achieved without complications when an accurate diagnosis and proper non-surgical or surgical treatment are performed based on this article.

Pediatric Fractures around the Wrist

Fractures around the wrist are the third most common fracture among all pediatric fractures. Furthermore, distal radius fractures, a type of wrist fracture, are the most common fractures in children. Understanding pediatric fractures around the wrist is very important considering their prevalence. There is a specific belief that pediatric fractures can heal easily because of remodeling, but not all fractures can heal without proper treatment. Complications such as growth problems, nonunion can occur if the fracture is not treated properly. This paper reviewed recent articles about distal radius fractures, Galeazzi-equivalent fractures, and carpal bone fractures, including scaphoid fractures in children and adolescents. Successful treatment can be achieved without complications when an accurate diagnosis and proper non-surgical or surgical treatment are performed based on this article.

Surgical Treatment of Patellar Instability in Children and Adolescents / 대한정형외과학회잡지

Patellar instability in children and adolescents is caused by abnormalities of various knee structures. Instability of the patellofemoral joint can manifest as an acute dislocation, recurrent dislocation, habitual dislocation, and congenital dislocation. Patellar instability is associated with abnormalities in the anatomical structures around the knee, and a comprehensive analysis of the cause should be undertaken. Surgery can be performed to reconstruct any abnormal musculo-skeletal alignment. Considerable progress has been made in the treatment of patellar instability in recent years, and surgical methods include lateral release, soft tissue realignment procedure, transfer of the autologous tendon, trochleaplasty, and reconstruction of the medial patellofemoral ligament.

Impact of Open Reduction on Surgical Strategies for Missed Monteggia Fracture in Children

PURPOSE: The aims of this study were to review our cases of missed Monteggia fracture treated by open reduction of the radial head with or without ulnar osteotomy and to investigate the indications for open reduction alone in surgical treatment of missed Monteggia fracture. MATERIALS AND METHODS: We retrospectively reviewed 22 patients who presented with missed Monteggia fracture. The patients' mean age at the time of surgery was 7.6 years. The mean interval from injury to surgery was 16.1 months. The surgical procedure consisted of open reduction of the radiocapitellar joint followed by ulnar osteotomy without reconstruction of the annular ligament. The mean period of follow-up was 3.8 years. Radiographic assessment was performed for the maximum ulnar bow (MUB) and the location of the MUB. Clinical results were evaluated with the Mayo Elbow Performance Index and Kim's scores. RESULTS: Five patients underwent open reduction alone, and 17 patients underwent open reduction and ulnar osteotomy. When the MUB was less than 4 mm and the location of the MUB was in the distal 40% of the ulna, we could achieve reduction of the radial head without ulnar osteotomy. The radial head was maintained in a completely reduced position in 21 patients and was dislocated in one patient at final follow-up. CONCLUSION: Open reduction alone can be an attractive surgical option in select patients with missed Monteggia fracture with minimal bowing of the distal ulna. However, ulnar osteotomy should be considered in patients with a definite ulnar deformity.

Effects of Soft Tissue Surgery on Pelvic and Hip Rotation in Patients with Spastic Diplegia: A Meta-Analysis

BACKGROUND: There are several different opinions regarding the improvements seen on the transverse plane after soft tissue surgery alone in independently ambulant patients with cerebral palsy. We performed a meta-analysis using data from previous studies to identify the effects of soft tissue surgery alone on pelvic and hip rotation in children with spastic diplegia. METHODS: We conducted a pilot study to evaluate the improvement in pelvic and hip rotation after muscle-tendon lengthening surgery in children with spastic diplegia. We also searched EMBASE and PubMed and selected 2 previous studies using the same test conditions with kinematic data on the pelvis and hip joints. A meta-analysis of the results of these 3 studies, including this pilot study, was then performed. RESULTS: The meta-analysis results showed an external rotation decrease (p = 0.005) in the mean difference of pelvic rotation of -3.61 (95% confidence interval [CI], -6.13 to -1.09) and a mean difference in hip rotation of 6.60 (95% CI, 3.34 to 9.86), indicating a significant increase in the hip external rotation after surgery (p < 0.001). CONCLUSIONS: In independently community-ambulant pediatric patients with spastic diplegia, pelvic retraction and hip internal rotation could be improved after soft tissue surgery.

Effects of Soft Tissue Surgery on Pelvic and Hip Rotation in Patients with Spastic Diplegia: A Meta-Analysis

BACKGROUND: There are several different opinions regarding the improvements seen on the transverse plane after soft tissue surgery alone in independently ambulant patients with cerebral palsy. We performed a meta-analysis using data from previous studies to identify the effects of soft tissue surgery alone on pelvic and hip rotation in children with spastic diplegia. METHODS: We conducted a pilot study to evaluate the improvement in pelvic and hip rotation after muscle-tendon lengthening surgery in children with spastic diplegia. We also searched EMBASE and PubMed and selected 2 previous studies using the same test conditions with kinematic data on the pelvis and hip joints. A meta-analysis of the results of these 3 studies, including this pilot study, was then performed. RESULTS: The meta-analysis results showed an external rotation decrease (p = 0.005) in the mean difference of pelvic rotation of -3.61 (95% confidence interval [CI], -6.13 to -1.09) and a mean difference in hip rotation of 6.60 (95% CI, 3.34 to 9.86), indicating a significant increase in the hip external rotation after surgery (p < 0.001). CONCLUSIONS: In independently community-ambulant pediatric patients with spastic diplegia, pelvic retraction and hip internal rotation could be improved after soft tissue surgery.

An accessory limb with an imperforate anus

Congenital accessory limbs are very rare anomalies with many causative factors. We describe the case of a 1-day-old female neonate-born to a healthy, 27-year-old mother-who presented with an accessory limb (foot) attached to the buttock and an imperforate anus. We also provide a review of the relevant literature.

Changes in Dynamic Pedobarography after Extensive Plantarmedial Release for Paralytic Pes Cavovarus

PURPOSE: Plantarmedial release and first ray extension osteotomy are often combined to treat paralytic cavovarus foot deformity. The purpose of this study is to evaluate the effect of additional first ray extension osteotomy in terms of dynamic pedobarography. MATERIALS AND METHODS: We reviewed findings of pre- and postoperative plain radiography and dynamic pedobarography for 25 patients in whom the flexibility of the hindfoot was confirmed by the Coleman block test. The results of treatment by extensive plantar medial release with first ray osteotomy (group I) were compared with the results of treatment by extensive plantar medial release alone (group II). RESULTS: Plain radiographs obtained pre- and postoperatively showed no statistically significant improvement in each group. Only in group I, peak forces at the 1st metatarsal head, 2nd metatarsal head and medial calcaneus were increased after operation. CONCLUSION: In paralytic hindfoot flexible cavovarus, extensive plantarmedial release with first ray osteotomy improve foot pressure distribution more than extensive plantarmedial release alone.

Gastrocnemius Architecture in Patients with Spastic Cerebral Palsy / 대한정형외과연구학회지

PURPOSE: Gastrocnemius muscle spasticity is a common finding in children with cerebral palsy (CP). However, the differences between spastic hemiplegic CP (SHCP) and spastic diplegic CP (SDCP) have not been compared. The purpose of this study was to compare the gastrocnemius architecture between the two CP groups and a control group, by using ultrasonography. MATERIALS AND METHODS: We enrolled 18 children with CP and 10 healthy controls. Patients with CP were categorized into two groups: 10 patients with SHCP and eight patients with SDCP. Ultrasonography images of the gastrocnemius were acquired at rest and with the knee at 0degrees with full ankle dorsiflexion. Fascicle lengths, pennation angles, and muscle widths were compared. RESULTS: SHCP demonstrated the most limited ankle dorsiflexion, and there were no significant differences in joint positions between the two CP groups at rest. Compared to healthy controls, fascicle lengths were diverse, but pennation angles and muscle width were similar or decreased in the two CP groups. There were no significant differences between SHCP and SDCP in fascicle length, pennation angle, and muscle width with the knee at 0degrees with ankle full dorsiflexion. At rest, the fascicle length of SHCP was longer than SDCP and the lateral gastrocnemius muscle width of SDCP was smaller than SHCP. CONCLUSION: A decreased pennation angle and muscle width are characteristic features of the gastrocnemius in patients with CP. There was little difference in the architecture of the gastrocnemius between SHCP and SDCP, despite different spasticity. A decreased pennation angle would be expected to decrease the excursion of the muscle during ankle dorsiflexion.

Operative Treatment of Pediatric Humeral Diaphyseal Fractures with Flexible Intramedullary Nails / 대한정형외과학회잡지

PURPOSE: Most humeral fractures of children are treated satisfactorily with conservative method, thus surgical treatment is often reserved for limited conditions. In cases of an open fracture, inadequate reduction or multiple traumas, children with humeral shaft fractures require operative treatment. The aim of our study was to evaluate results and complications of pediatric humeral shaft fractures that were treated with flexible intramedullary nails. MATERIALS AND METHODS: A retrospective study was performed for 12 patients who were treated operatively by flexible intramedullary nails between March 2009 and September 2011. Surgical indications were an open fracture, an inability to maintain an adequate reduction, concomitant fractures, refractures and combined radial nerve injury. All patients were treated with 2 titanium flexible intramedullary nails by antegrade or retrograde techniques, according to the site of the fractures. RESULTS: The mean follow-up period was 15 months, and all patients achieved union status without major complications. There were no neurovascular injuries or infection during surgical procedures. However, 4 patients showed irritation at the insertion site of the nail, and 2 of them underwent early removal of nails at about 6 weeks due to skin lesions as well as pain and discomfort. One boy showed a fracture next to the proximal insertion site of the antegrade nail. All patients showed a full range of motion, and went back to daily life by the final follow-up. CONCLUSION: Flexible intramedullary nails are considered as a good option for the fracture of the pediatric humeral shaft. Surgeons should pay attention and use proper techniques to avoid complications.

Effect of the Number of Involved Spinal Cord Segments on Gait Function in Patients with Cervical Spondylotic Myelopathy

STUDY DESIGN: Retrospective. PURPOSE: To determine the effect of severity of cervical spondylotic myelopathy (CSM) on gait parameters according to the number of involved spinal cord segments. OVERVIEW OF LITERATURE: Although there are a large number of studies on CSM, almost all studies have focused on hand function and only a few studies have examined the gait function in patients with CSM. METHODS: Twenty-three patients with CSM underwent magnetic resonance imaging and gait analysis. The subjects were divided into 2 groups; group I consisted of 9 patients with a single-level stenotic lesion and group II comprised 14 patients with multi-level stenotic lesions. Gait parameters were compared between the 2 groups and the normal control group. RESULTS: There was no significant difference in the Japanese Orthopaedic Association score between the 2 groups. Cadence, walking speed, stride length, and step length were decreased in group II compared to group I and normal control group. Peak ankle plantar flexion moments during the stance phase and peak knee flexion angle during the swing phase were decreased in group II. Peak ankle, knee, and hi p power generation during the stance phase were decreased in group II; in addition, the peak ankle power generation was decreased in group II than in the normal control group. CONCLUSIONS: Patients with multi-level stenotic lesions had decreased gait ability compared to that in patients with a single-level stenotic lesion. The number of involved spinal cord segments can be one cause of gait deterioration in patients with CSM. Performing a gait analysis is useful for accurate evaluation of the patient.

Treatment of Medial Epicondyle Fracture without Associated Elbow Dislocation in Older Children and Adolescents

PURPOSE: Displaced medial humeral epicondyle fractures with or without elbow dislocation have been treated with open reduction and fixation using K-wires or screws. The purpose of this study is to evaluate the clinical and radiological outcomes of surgical treatments of medial humeral epicondyle fracture without elbow dislocation according to the fixation methods. MATERIALS AND METHODS: Thirty-one patients who had undergone open reduction and fixation of the displaced medial humeral epicondyle fracture without elbow dislocation were included. Group I consisted of 21 patients who underwent fixation with K-wires, and Group II comprised 10 patients who underwent fixation with cannulated screws. Immediate postoperative, final follow-up and normal anteroposterior radiographs were compared and the clinical outcome was assessed using the final Japanese Orthopaedic Association (JOA) elbow assessment score. RESULTS: On the immediate postoperative radiographs, the distal humeral width in Group II was larger than that in Group I. On the final follow-up radiographs, the epicondylar position in Group I was lower than that in Group II. There was no significant difference in the distal humeral width, epicondylar position and joint space tilt between the immediate postoperative, final follow-up radiographs and the normal side within each group. There was no significant difference in the final JOA score between groups. CONCLUSION: Open reduction followed by K-wire fixation or screw fixation of the displaced medial humeral epicondyle fracture without elbow dislocation in older children and adolescents resulted in improved radiologic outcome and good elbow function in spite of diverse radiologic deformities.

Changes of the Muscle-tendon Lengths in a Three-dimensional Musculoskeletal Model according to the Hip Transverse Angle in Cerebral Palsy Patients with Crouch Gait / 대한정형외과학회잡지

PURPOSE: Crouch gait is one of the common pathologic gaits in children with cerebral palsy. Hamstring lengthening for alleviation of knee flexion is often considered as a first choice for the treatment of crouch gait. However, there have been a variety of reports about the lengths of the hamstring muscle. The purpose of this study was to classify the crouch gait on the transverse plane and to suggest a guide line for hamstring lengthening by analyzing the length of these muscles. MATERIALS AND METHODS: The subjects for this study were selected in ambulatory spastic diplegia patients with crouch gait. A total of sixty-two patients (124 cases) were included. The gait parameters and the muscle lengths were compared. The range of +/-1 standard deviation of the normal middle stance hip rotation was considered as the normal range. The subjects were divided into three groups as hip external rotated (group I), normal (group II) and hip internal rotated (group III) according to the hip rotation. RESULTS: The flexion of the knee and hip was the greatest in group III and dorsiflexion of the ankle was the least in group I. On comparison of moment and power on the sagittal plane, there was no significant difference among the groups. In group III, the percent lengths of the adductor, biceps femoris and gracilis muscles were increased the most, whereas the percent length of the semimembranosus was decreased the most. There was no statistical difference between groups I and II and the normal control group. CONCLUSION: Irrespective of the hip rotation, the length of the hamstring muscle in patients with crouch gait did not differ compared to that of the normal control. But if rotational osteotomy is done for the correction of the increased femoral anteversion in group III, then we should consider lengthening the semimembranosus muscle.

Delayed Diagnosed Stage 1, 2 Distractive Flexion Injury of the Cervical Spine

STUDY DESIGN: Retrospective study. PURPOSE: To examine the clinical and radiologic characteristics of patients with stage 1 and 2 distractive flexion injury according to Allen's classification and who were not diagnosed immediately after injury, and to analyze the outcomes of surgical treatments. OVERVIEW OF LITERATURE: For the diagnosis of stage 1 and 2 distractive flexion injury in the lower cervical spine, attention should be paid when performing radiographs as well as when interpreting the radiographs. METHODS: The study was conducted on 10 patients (group 1) with stage 1 or 2 distractive flexion injury and who were not diagnosed immediately after injury from January 2003 to January 2009. The control group (group 2), 16 distractive flexion injury patients who were diagnosed immediately were selected. The simple radiographs, the degree of soft tissue swelling and the magnetic resonance imaging findings of the two groups were compared, and the clinical and radiologic results were examined. RESULTS: The degree of the prevertebral soft tissue swelling of group 1 was lower in group 1, and it was statistically significant (p = 0.046). The fusion was achieved in all cases (100%) in group 1, however, re-displacement as well as the loss of reduction occurred in one case, despite of delayed fusion and good clinical result. In group 2, bone fusion was achieved in 15 cases of 16 cases (94%). CONCLUSIONS: For the diagnosis of stage 1 and 2 distractive flexion injury in the lower cervical spine, it is desirable to perform computed tomography if diagnosis is not clear. Even if the diagnosis is delayed, stage 1 and 2 distractive flexion injury could be readily reduced by traction, and the treatment outcomes are considered to be comparable to those of the patients diagnosed immediately after injury.

Necrotizing Fasciitis in a 7-day-old Term Healthy Neonate

Necrotizing fasciitis is a rare, but life-threatening infection. Prompt diagnosis and early aggressive intervention is required for survival. However, there has been frequently occurred in delays of diagnosis and treatment due to its non-specific nature. Therefore, a high index of suspicion is needed to ensure timely intervention. We report a case of necrotizing fasciitis in a 7-day-old term healthy neonate.

Extraarticular Subtalar Arthrodesis for Pes Planovalgus: An Interim Result of 50 Feet in Patients with Spastic Diplegia

BACKGROUND: There are no reports of the pressure changes across the foot after extraarticular subtalar arthrodesis for a planovalgus foot deformity in cerebral palsy. This paper reviews our results of extraarticular subtalar arthrodesis using a cannulated screw and cancellous bone graft. METHODS: Fifty planovalgus feet in 30 patients with spastic diplegia were included. The mean age at the time of surgery was 9 years, and the mean follow-up period was 3 years. The radiographic, gait, and dynamic foot pressure changes after surgery were investigated. RESULTS: All patients showed union and no recurrence of the deformity. Correction of the abduction of the forefoot, subluxation of the talonavicular joint, and the hindfoot valgus was confirmed radiographically. However, the calcaneal pitch was not improved significantly after surgery. Peak dorsiflexion of the ankle during the stance phase was increased after surgery, and the peak plantarflexion at push off was decreased. The peak ankle plantar flexion moment and power were also decreased. Postoperative elevation of the medial longitudinal arch was expressed as a decreased relative vertical impulse of the medial midfoot and an increased relative vertical impulse (RVI) of the lateral midfoot. However, the lower than normal RVI of the 1st and 2nd metatarsal head after surgery suggested uncorrected forefoot supination. The anteroposterior and lateral paths of the center of pressure were improved postoperatively. CONCLUSIONS: Our experience suggests that the index operation reliably corrects the hindfoot valgus in patients with spastic diplegia. Although the operation corrects the plantar flexion of the talus, it does not necessarily correct the plantarflexed calcaneus and forefoot supination. However, these findings are short-term and longer term observations will be needed.

Reliability of the Radiographic Parameters in Pediatric Supracondylar Fracture

PURPOSE: To suggest the most reliable guideline of the treatement for the supracondylar fracture in children by the comparison of the radiographic parameters between forearm supination-elbow extension and forearm pronation-elbow flexion view. MATERIALS AND METHODS: A total of seventy-one patients were included in the study. Baumann, metaphyseal diaphyseal and medial epicondylar epiphyseal angle of normal elbow in extension and flexion view were compared. Finally, the results of Group I (operation with elbow extension view) and Group II (operation with elbow flexion view) were compared. RESULTS: Intraobserver reproducibility and interobserver reliability were better in the Baumann angle with extension view and metaphyseal diaphyseal angle with flexion view. In extension view, Baumann and metaphyseal diaphyseal angle show negative correlation with carrying angle but in flexion view, only metaphyseal diaphyseal angle shows negative correlation. Baumann angle were greater in flexion view and medial epicondylar epiphyseal angle were greater in extension view. There was no statistical difference in the final results of Group I and II. CONCLUSION: Baumann angle was more effective in forearm supination-elbow extension view and metaphyseal diaphyseal angle was more effective in forearm pronation-elbow flexion view. The difference between elbow extension and flexion view should be considered during operation.

Effects of Heat Shock and Antioxidant on the Growth Plate of Unloaded Rats / 대한정형외과연구학회지

PURPOSE: This study was performed to examine any histopathological changes occurring in the growth plate when the rats were subjected to be deprived of normal weight bearing using the hindlimb suspension model, and to search for any countermeasures for improving and/or recovering the chondrocyte activities within the growth plate. MATERIALS AND METHODS: Sixty male Sprague-Dawley rats, aged 6 weeks, were divided into 10 groups each: Group I-control to unloading; Group II-unloading 3 weeks only; Group III-unloading+application of heat shock; Group IV-unloading+application of antioxidant; Group V-unloading+application of heat shock and antioxidant; Group VI-control to reloading; Group VII-reloading 1 week only; Group VIII-reloading+application of heat shock; Group IX-reloading+application of antioxidant; Group X-reloading+application of heat shock and antioxidant. The animals were double labeled with 5-Bromo-2'-deoxydiuridin (BrdU) and BrdU immunohistochemistry was performed for the cellular kinetic analysis. Transferase-mediated deoxyuridine triphosphate-biotin nick end labeling (TUNEL) assay was done for the investigation of apoptotic changes in the growth plate, and the positive cells were counted in each zones of the growth plate in both TUNEL and BrdU immunohistochemistry. Heat shock protein (HSP), indian hedgehog (Ihh), and vascular endothelial growth factor (VEGF) were immunolocalized to assess the chondrocytic activities in terms of production of extracellular matrix protein. RESULTS: Non-weight bearing induced a reduction of height of the growth plate, reduced cellular proliferation of chondrocytes, reduced expression of Ihh and VEGF, and altered expression of heat shock protein. When heat shock and/or antioxidant were applied to the unloaded and reloaded rats, only rats in the group of application of both heat shock and antioxidant showed normal cellular activities in terms of cellular proliferation and the production of extracellular matrix protein. CONCLUSION: The present results suggest that application of heat shock and antioxidant would be a countermeasure for the restoration of chondrocytic activities when the normal weight-bearing is deprived of.