A comparison of patients with different types of syndactyly.

We performed a retrospective review of finger syndactyly releases at Shriners Hospital for Children, Houston Unit, between January 1983 and January 1993. This study was performed in an attempt to compare the long-term postoperative function in patients after release of syndactyly resulting from Poland's syndrome with that in patients with idiopathic forms of syndactyly. Only patients with one involved hand were included in this study. The contralateral hand was used as a control. Twenty-seven patients with only one hand involved underwent syndactyly release during this period. Of these, 13 patients who underwent a total of 30 syndactyly releases were available for evaluation. For each patient, the type of syndactyly was determined. Each patient was subjected to a detailed physical examination and participated in occupational-therapy modalities. We noted statistically significant differences in function between operated-on and control hands in the Poland's group, whereas operated-on hands affected with idiopathic forms of syndactyly did not demonstrate significantly different function compared with contralateral controls. These data suggest that functional deficits in hands affected by Poland's syndrome are attributable to more than the syndactyly alone. Hands affected by idiopathic forms of syndactyly are likely to have little postoperative functional deficit.

Adductor transfers in cerebral palsy: long-term results studied by gait analysis.

Thirty-three ambulatory patients with spastic cerebral palsy underwent evaluation and gait analysis an average of 9.6 years after bilateral posterior adductor transfers to the ischium. All patients showed functional improvement postoperatively, which was maintained at long-term follow-up in 94%. Gait analysis, however, documented pelvic obliquity in 85% of this group of patients. Associated with pelvic obliquity was a 36% incidence of unilateral hip subluxation. These complications of posterior adductor transfers have been difficult to treat and have resulted in the abandonment of this procedure at our institution.

Percutaneous vs modified phemister epiphysiodesis of the lower extremity.

Epiphysiodesis of the lower extremity for limb-length discrepancy has been performed on 24 patients by both the modified Phemister and a percutaneous method. The primary complication of epiphysiodesis by both methods was continued growth of the physeal plate (12% and 15%, respectively). Failure of epiphysiodesis was attributed to young skeletal age at surgery in three of five cases. Closer attention to physeal ablation and close follow up should prevent this complication. No angular deformities resulted in any patient. During 16 proximal fibular procedures, there were no neurologic complications. The percutaneous method is preferred due to ease of surgical procedure, minimal incisions, limited disability to the normal extremity, and equal results.

Reconstitution of the patellar tendon donor site after graft harvest.

Little is known about the fate of the donor site after the central 1/3 of the patellar tendon is harvested for anterior cruciate ligament reconstruction. This study evaluated the donor site in the patellar tendon at various times after a graft from the central 1/3 of the patellar tendon was harvested. Fourteen patients were studied with magnetic resonance images taken from 6 weeks to 2 years after anterior cruciate ligament reconstruction. Axial, sagittal, and coronal views of the patellar tendon were obtained. A second group of 8 patients who had previous anterior cruciate ligament reconstruction were returned to the operating room for subsequent procedures on the affected knee. These procedures were performed 2 to 24 months after the original reconstruction. An open biopsy was obtained from the donor site in the patellar tendon. On magnetic resonance images, the size of the defect and the intensity of the signal in the central 1/3 of the tendon decreased with time from surgery. At 2 years, the defect was indistinguishable from normal tendon. Histologically, the scar in the defect progressively matured with time, becoming nearly identical to normal tendon at 2 years.

Dennyson-Fulford subtalar arthrodesis.

Forty-six patients who had undergone Dennyson-Fulford subtalar arthrodesis for hindfoot valgus deformities secondary to various pathologies were reviewed both radiographically and clinically. Mean age at surgery was 7.67 years; mean follow-up was 5.67 years. Evaluation showed 70% good, 20% fair, and 10% poor results. Pseudarthrosis rate was 6.4%, and was not necessarily related to undercorrection or progressive deformity. Screw sclerosis, which is common, is associated with pseudarthrosis, but not with hardware failure. Hardware problems can be anticipated with intraoperative radiographs, and penetration of the lateral calcaneal cortex up to 1.0 cm is well tolerated.

Preoperative and postoperative assessment of surgical intervention for equinus gait in children with cerebral palsy.

We compared the effects of different methods of surgical correction of equinus gait in children with spastic cerebral palsy (CP) using pre- and postoperative measurements of gait, electromyography (EMG), range of motion (ROM), and dynamic ankle motion. Operative results significantly improved all variables that produced more normal ankle motion in subjects, although no differences were observed between surgical methods. We conclude that preoperative gait analysis can assist in surgical planning regardless of surgical method for Achilles lengthening and can provide an objective measure of results after surgical correction of equinus deformity.

Closed femoral shortening.

Eighteen patients underwent closed intramedullary femoral shortening at a children's teaching hospital. Their average age was 16 years 2 months (range 14-18 years). Clinical and radiographic union was obtained in < or = 3 months in all patients. Shortening averaged 4.4 cm (range 3-5 cm). Complications included one case of acute respiratory distress and three cases of fixation loss. We describe the procedure for closed intramedullary rodding without use of a fracture table and recommend (a) that reaming proceed slowly through an enlarged proximal portal, and (b) that in all cases nails be interlocked both proximally and distally.

Intramedullary fixation for congenital pseudarthrosis of the tibia.

Eighteen consecutively seen patients who had a congenital pseudarthrosis of the tibia were treated operatively. The mean age when the patients were first seen was four years. Seventeen previous procedures had failed: six patients had had one previous procedure; three, two previous procedures; and one, five previous procedures. At an average follow-up interval of ten years (range, three to nineteen years), healing with re-formation of the medullary canal was seen in thirteen of the eighteen tibiae, including one tibia that had united after a Boyd amputation. Five patients did not have healing of the tibia: four of them had a below-the-knee amputation, and one declined additional treatment. The average residual angulation was 12 degrees in the sagittal plane and 5 degrees in the coronal plane. Union occurred in ten of the thirteen patients who had been managed with intramedullary fixation. Of these thirteen, eight had been managed with intramedullary fixation, bone-grafting, and implantation of an electrical stimulator, and seven of them had union. Five of the thirteen patients had been managed with intramedullary fixation and bone-grafting, and three of them had union. Union occurred in one of two patients who had been managed with vascularized free fibular transfer, one who had been managed with delayed bone-grafting, and one who had been managed with a Boyd amputation. Four of the five patients who did not have union were subsequently managed with a below-the-knee amputation, and one patient refused additional treatment.

Surgical correction of severe knee pterygium.

Knee flexion contracture secondary to a severe pterygium is a disabling condition. Full surgical correction has not been possible because of the sciatic nerve and its terminal branches. Our technique to obtain full correction is to divide the nerve near the neuromuscular junction and bridge the defect with multiple sural nerve cable grafts. Microscopic technique is used.

Triple arthrodesis in young children: a salvage procedure after failed releases in severely affected feet.

A total of 19 triple arthrodeses were performed in 13 children aged 10 years or less for severe hindfoot deformities after failure of soft tissue releases. This was considered a salvage procedure and an alternative to talectomy. The average age at surgery was 8.4 years and average follow-up was 4 years. There were 68% excellent and good results, 16% fair, and 16% poor results. The nonunion rate was 7% of joints. Average shortening of the foot was 0.81 in but was not significant when compared with a group of clubfoot control patients. Except for one infection, fair and poor results were due to residual rather than recurrent deformity. Triple arthrodesis may be indicated in the young child for residual hindfoot deformity as an alternative to talectomy. The potential problems of increased nonunion, severe compromise of foot length, and recurrence of deformity were not observed in this series.

Surgical management of arthrogryposis in the upper extremity.

Arthrogryposis multiplex congenita is a rare congenital disorder in which the extremities are affected with severe resistant musculoskeletal contractures. In the upper extremity, these deformities typically consist of internal rotational contractures of the shoulder, extension deformity of the elbow, flexion and ulnar deviation of the wrist, thumb-in-palm deformity, and digital interphalangeal joint flexion contractures occurring singularly or in combination. At the Houston Unit of the Shriners Hospital for Crippled Children, during the interval from 1962 to 1982, 25 patients underwent 56 operative procedures to correct upper-extremity deformities due to arthrogryposis multiplex congenita. Functional improvement was observed clinically and reported subjectively by the patients or their parents in 75% of the cases.

The appearance of the tarsal navicular after posteromedial release for clubfoot.

Sixty-one idiopathic clubfeet in 46 patients of an older population were treated by one-stage posteromedial release. Follow-up roentgenograms revealed dorsal subluxation of the tarsal navicular in 43% of the clubfeet. This abnormality is probably due to both closed manipulation and casting, and improper positioning of the navicular during posteromedial release. However, dorsal navicular subluxation did not adversely affect the results of treatment observed over the follow-up period that averaged nearly 6 1/2 years. Medial subluxation of the navicular was associated with unsatisfactory results, whereas a centrally located or laterally subluxed navicular generally produced good or excellent results. Other abnormalities of the navicular noted included wedging and avascular necrosis. The long-term consequences of these various abnormalities of the roentgenographic appearance and position of the navicular are not known.

Surgical therapy for congenital dislocation of the hip in patients who are twelve to thirty-six months old.

Over a ten-year period, fifty-one congenitally dislocated hips in forty-one patients, whose ages ranged from twelve to thirty-six months, required open reduction. Supplemental procedures such as derotational osteotomy, pericapsular (Pemberton) osteotomy, and femoral shortening were performed as necessary. All of the patients have been followed for at least two years (average, 6.1 years). No patient had a significant limp, Trendelenburg gait, or avascular necrosis. Using Severin's classification of radiographic evaluation, twenty-nine hips (57 per cent) were rate as excellent and eighteen hips (35 per cent), as good. In our experience, open reduction of the hip together with correction of acetabular and femoral deformities affords the patient in the one to three-year-old age range an excellent chance of obtaining an anatomically satisfactory hip.

Performance of an athlete with straight posterior knee instability.

Isolated posterior ligamentous insufficiency of the knee frequently terminates an athlete's career and may even adversely affect the performance of tasks of daily living. Return to competitive athletics following surgical reconstruction for posterior instability is unusual. The pathophysiology of the lesion and a biomechanical analysis are discussed. A case report of an athlete with a ruptured posterior cruciate ligament who is presently successfully competing in professional football is also presented. Rigorous quantitative techniques were employed to document the compensatory mechanisms involved. These consisted of extremely strong quadriceps muscles contracting much earlier than normal in the gait cycle. Earlier quadriceps contraction to increase dynamic stability in the knee is able to overcome the instability resulting from the incompetent posterior cruciate ligament.

Use of the air-inflated jacket in football.

Injuries to the rib cage are common in football, but little has been done to protect this area. This paper discusses the effectiveness and usefulness of a protective jacket in football. The jacket is highly durable, constructed of urethane-coated nylon, and heat-sealed to take on the shape of several cylinders interconnected by fabric valves which constrict in response to a sudden blow. Its exterior is covered by a 1/8-inch thick Lexan (General Electric, Toledo, OH) shield. The jacket weighs 6.5 oz. It showed impressive results when tested. Testing was done by forcefully swinging a baseball bat against the rib cage protected by the jacket. By digitization of high speed movie filming at 500 frames/second, we were able to determine the speed, velocity, and area of contact. The amount of force deflection was calculated to be 587.6 psi. To inflict this force, a player would have to be traveling 60 miles/hour and strike his opponent with the heel. This lightweight, air-inflated, padded jacket has protected and prevented rib cage injuries in professional athletes. It is accepted well by players. This suggests that similar protective equipment for other areas would be useful and represents an advancement in preventing injury.