Modified split tendon transfer of posterior tibialis muscle in the treatment of spastic equinovarus foot deformity: long-term results and comparison with the standard procedure.

INTRODUCTION: Split tendon transfer of tibialis posterior (SPOTT) is a treatment option for the hindfoot varus deformity in patients with cerebral palsy (CP). The purpose of this study was to present the long-term results of the newly modified SPOTT procedure developed by our senior author and compare it with the standard SPOTT technique in equinovarus foot deformity due to CP. METHOD: Our retrospective cohort study included patients with spastic foot deformity due to CP treated with the standard or modified SPOTT technique. Patients' age at the time of the surgery was ≥ five years with follow-up period of at least four years. Surgical outcomes were evaluated using Kling's criteria during the patient's last follow-up visit. RESULTS: The analysis included 124 patients (146 feet), where 105 feet were treated by the standard SPOTT technique and 41 feet by the modified SPOTT technique. Patients' median age at the time of the surgery was 11 years. Patients were followed-up for a median period of eight years during which the modified SPOTT technique showed significantly better surgical outcomes compared with the standard group (excellent/good results in 38 feet, 92.7%, vs. 79 feet, 75.2%, p = 0.02). Two groups of patients did not significantly differ in GMFCS level, age at the time of the surgery, or patient gender. There was similar distribution in CP patterns in the standard and modified groups; spastic hemiplegia was the most prevalent form, followed by spastic diplegia and spastic paraplegia. Overall, better surgical success was achieved in patients with GMFCS levels I-III (100%, 94.8%, and 69.8%, respectively). SPOTT procedure failure was frequently noticed in patients with GMFCS level IV (90.9%). CONCLUSION: The modified SPOTT procedure demonstrated efficiency and safety in patients with equinovarus foot deformity due to CP during the long-term follow-up. Compared with the standard procedure, the newly modified SPOTT technique showed significantly better surgical outcome, irrespective of the patients' gender, age, initial GMFCS level, and CP type.

The results of surgical treatment for pronation deformities of the forearm in cerebral palsy after a mean follow-up of 17.5 years.

AIM: This study evaluates the effects of three surgical procedures in the treatment of pronation deformities of the forearm in cerebral palsy patients; namely the transposition of pronator teres to extensor carpi radialis brevis muscle; and rerouting of the pronator teres muscle with or without pronator quadratus muscle myotomy. METHODS: Sixty-one patients, 48 male/13 female, with a mean age of 17 years (5-41 years) were treated between 1971 and 2011. Pronator teres transposition was performed in 10, pronator rerouting in 35, and pronator rereouting with pronator quadratus myotomy in 16 patients. Ranges of motion, and assessments using the Quick Dash, Mayo Scoring, and Functional Classification system of upper extremity, were made before and after surgery. Mean follow-up was 17.5 years (3-41 years). RESULTS: All three procedures led to significantly improved ranges of motion and upper limb function, with good/excellent results in 80 % of patients. Mean active supination improved from 10 ° (0-60 °) to 85 ° (30-90 °) (p < 0.001). There were significant improvements in Functional Classification system for the upper extremity scores (p < 0.003), Mean Quick Dash Scores improved from 58.41 (38.63-79.54) to 44.59 (27.27-68.18), and mean MEPS improved from 68 (30-85) to 84 (60-100) following surgery. All three techniques had statistically improved MEPS following surgery (p < 0.001); only the pronator teres muscle rerouting with pronator quadratus myotomy showed an improved Functional Classification system for the upper extremity score (p < 0.05); and only the pronator teres rerouting procedure showed an improved Quick Dash score (p < 0.05). There were no statistically significant differences in outcomes between different ages groups, and no significant differences between isolated pronator teres muscle rerouting were compared with those undergoing simultaneous treatment of carpal flexion and thumb adduction deformities (p > 0.05). CONCLUSION: Surgery is very effective in the management of pronation deformities of the forearm in patients with cerebral palsy. Isolated pronator teres rerouting is probably the most effective and simple technique. Adjunctive pronator quadratus myotomy does not lead to an improvement in the results and requires an additional surgical approach. There should be no age restriction to surgery, as all age groups appear to benefit from similar improvements in range of motion and upper limb function.

The management of humeral shaft fractures with associated radial nerve palsy: a review of 117 cases.

PATIENTS AND METHODS: This single center retrospective study reviews the management and outcomes of 117 consecutive patients with humeral shaft fractures and associated radial nerve palsy (RNP) treated over a 20-year period (1986-2006). A total of 101 fractures were managed conservatively and 16 fractures underwent external fixation for poor bony alignment. Sixteen grade 1 and 2 open fractures underwent wound toileting alone. No patients underwent initial radial nerve exploration or opening of the fracture sites. RESULTS: All patients achieved clinical and radiological bony union at a mean of 8 weeks (range 7-12 weeks). There were no complications or pin tract infections in the operated patients. A total of 111 cases had initial spontaneous RNP recovery at a mean of 6 weeks (range 3-24 weeks) with full RNP recovery at a mean of 17 weeks (range 3-70 weeks) post-injury. Fourteen patients had no clinical/EMG signs of nerve activity at 12 weeks and 6 subsequently failed to regain any radial nerve recovery; 2 had late explorations and the lacerated nerves underwent sural nerve cable neurorraphy; and 4 patients underwent delayed tendon transposition 2-3 years after initial injury, with good/excellent functional outcomes. CONCLUSIONS: Humeral fractures with associated RNP may be treated expectantly. With low rates of humeral nonunion, 95% spontaneous nerve recovery in closed fractures and 94% in grade 1 and 2 open fractures, one has the opportunity of waiting. If at 10-12 weeks there are no clinical/EMG signs of recovery, then nerve exploration/secondary reconstruction is indicated. Late tendon transfers may also give good/excellent functional results.

[Martin Kirschner (1879-1942): the founder of modern trauma clinics and emergency medicine]. / Martin Kirsner (1879-1942), tvorac moderne sluzbe traumatologije u urgentne medicine.

German surgeon Martin Kirschner (1879-1942) made a significant contribution not only to the general surgery but to orthopaedic surgery, traumatology and pain therapy as well. He gave a huge contribution to the institutions where he worked (Köningsberg), and some of them he had even built from the foundation (Tübingen, Heidelberg). He also established mobile hospitals and is the forefather of the trauma service and emergency medicine. In orthopaedics, he remains renowned for skeletal tractions, bone elongations, invention of thin wire, which is still widely used today in external fixation and which was named after him as Kirschner wire.

Triple pelvic osteotomy in the treatment of Legg-Calve-Perthes disease.

This article presents the results of Legg-Calve-Perthes (LCP) disease treatment using triple pelvic osteotomy. Thirty patients were analysed. The conditions for inclusion in the study were complete medical documentation and follow-up until the disease was resolved. Postoperatively, no patients were immobilised. Rehabilitation was initiated early in all patients, and full weight bearing was allowed after ten weeks. With this method, an increase of the CE angle of 17.43 +/- 4.020 degrees was achieved. Containment was increased from an initial 6.67% to 53.33% of patients at the final check-up. Similar improvement was achieved by using Herring classification of the damage; preoperatively most hips belonged to group C, and postoperatively to group A. Postoperatively, functional results were also considerably improved. The authors recommend triple pelvic osteotomy as the method of choice in the treatment of severe cases of LCP disease.

[Paralytic dislocations of the hip in adolescence--orthopaedic treatment].

Paralytic dislocation of the hip in adolescence is not typical, but presents a serious problem whether diagnosed primarily in adolescence or due to the lack of treatment or failed treatment in earlier age. It is characteristic of cerebral palsy and myelomeningocele. If the paralytic dislocation of the hip in adolescence is asymmetric, then pelvic obliquity, leg-length discrepancy, imbalance in sitting position, scoliosis and secondary spondylosis with all its consequences ensue. Complications like hip pains due to secondary arthrosis and walking ability impairment are frequent in ambulatory patients. The dislocation is the result of muscle imbalances in the hip region. The diagnosis is based on Illness history, clinical examination, neurological examination and radiography. Treatment is mostly operative, except in cases of pelvic symmetry and absence of difficulties. Pelvic and/or femoral osteotomy with or without open reduction of the hip is done in ambulatory patients with cerebral palsy. Soft-tissue surgery, hip flexors release and tenotomy of the hip adductors, are done in non-ambulatory patients with cerebral palsy. In patients with myelomeningocele soft-tissue surgery, hip flexors release and tractus iliotibialis resection on the lower side of the pelvis, are done regardless of the ability to walk. The same bone surgery procedures as in cerebral palsy are done only in ambulatory patients with unilateral dislocations if soft-tissue surgery failed.

A radiographic and clinical comparison of two soft-tissue procedures for paralytic subluxation of the hip in cerebral palsy.

This article summarises a comparative retrospective study (1983-2001) of 42 consecutive spastic-diplegic ambulatory patients (aged 2-10 years) by examining the radiographic and clinical results of two soft-tissue procedures for paralytic hip subluxation (PSH). Group A comprised 20 patients (26 PSHs) who were treated by iliopsoas tenotomy, and group B comprised 22 patients (31 PSHs) who were treated by rectus femoris and iliopsoas tenotomy with iliac crest resection (sartorius release). All patients had bilateral adductor tenotomies. At 8.8 years mean follow-up, group A migration percentages (MP) improved from 39.8% to 24.7% with 92.3% good/average results. At a mean follow-up period of 8.3 years, group B improved from 58.0% to 25.9% with 96.8% good/average results. Long-term hip reduction was achieved in 84.6% of group A and 80.6% of group B hips. Relative MP correction was superior in group B. No patient had MP progression in either the PSH or non-PSH hip. Walking ability improved in 55% of group A and 86% of group B patients (Functional Mobility Scale). In conclusion, we recommend release of all the principle hip flexors: rectus femoris, sartorius, and iliopsoas, coupled with adductor tenotomies, in this patient group.

[Sequelae of septic hip arthritis in infancy].

Septic arthritis of the hip represents a serious pathological condition which results in severe sequelae and high invalidity. The most serious sequelae are seen in neonatal and infantile period, when normal growth and development are brutally disturbed, followed by proximal femoral destruction and acetabular dysplasia, which in return result in anatomical limb shortening and functional deficiency. In order to achieve an adequate approach to the treatment of septic hip arthritis sequelae, different classification systems have been developed. Two of them are the most cited in literature: classification according to Hunka, and that according to Choi and associates. In this article, the authors compared both classification systems, presented their similarities and differences, and expanded them in view of treatment options applicable to each category. Although both classifications are based on radiographic findings, it has been shown that they clearly tell between treatment options relevant to particular type of sequelae of the septic hip arthritis, thus representing a useful tool in making decision about adequate treatment.

[Septic arthritis of the hip in infancy--diagnostic and therapeutic possibilities].

Septic arthritis of the hip in infancy is a serious condition which, if left untreated, results in disastrous sequelae and gross invalidity. Treatment is difficult and requires precise perception of characteristic clinical symptoms and signs, application of appropriate diagnostic procedures (laboratory analyses, ultrasound, radiography, joint aspiration, and occasionally additional methods), as well as parenteral administration of adequate antibiotics and obligatory surgical treatment. Differential-diagnostic spectrum of conditions similar to septic hip arthritis is large and diverse. Successful treatment is based on establishing the diagnosis on time, which is only achievable by methodical application of diagnostic protocol for septic hip arthritis in all suspected cases.

Femoral derotation osteotomy in cerebral palsy: precise determination by tables.

Femoral derotation osteotomy is used to treat increased femoral neck anteversion and to correct medial hip rotation deformity in patients with cerebral palsy. We investigated if there were significant differences between planned and achieved corrections of increased femoral neck anteversion and whether our method influenced walking ability and number of complaints. We retrospectively evaluated 17 ambulatory patients (21 femurs) with cerebral palsy and medial rotation deformity of the hip. The new method of determining femoral derotation osteotomy precisely and simply using tables was applied. The average followup was 11 years (range, 3-20 years), and the average age of the patients was 20 years (range, 9-42 years). The average planned correction of femoral neck anteversion was 31.9 degrees (range, 20 degrees - 45 degrees), and the average achieved correction was 32.19 degrees (range, 15 degrees - 40 degrees). Of the 17 patients evaluated, 13 no longer had complaints. Deterioration of walking ability was not observed in any patients. The new method of determining femoral derotation osteotomy precisely and simply corrects femoral neck ante- version in patients with cerebral palsy and medial rotation deformity of the hip, leading to reduction in complaints and improved walking ability.

[Medial rotation deformity of the hip in cerebral palsy: surgical treatment by transposition of gluteal muscles].

INTRODUCTION: Medial rotation deformity of the hip is a problem to patients who are handicapped by cerebral palsy but able to walk, because the knees point inward during gait ("kissing patellae") and cause falls and frequent injuries. Knees and ankles are subject to stress and, therefore, they assume compensating positions. Lower legs assume position of valgus and external rotation, whereas feet rotate either inwards or outwards. Secondary deformities make gait more difficult and cause rapid tear of footwear. AIM: The purpose of the paper was to retrospectively analyze the effects of transposition of the gluteus medius and minimus muscles, a procedure introduced for the first time in our country in order to correct the deformity. A new method of binding the muscles by wire was described. There had been no previous experience with this method. METHOD: This operation was indicated in patients with spastic form of cerebral palsy, who were able to walk, who had difficulties in gait and whose lateral rotation was less than 10 degrees along with the medial rotation of over 70 degrees of the hip on the side of the deformity. Additional prerequisite for the operation was the absence of flexion contracture of more than 15 degrees of either the hip or the knee on the side of deformity, as there is possibility of aggravation of the flexion hip deformity due to transposed gluteal muscles (now in front of the hip joint). Fifteen hips of 10 patients were operated on. Five patients were operated on bilaterally at one time. The average age was 8 (6-12) years. The majority of patients, 8 (80%) were aged between 6 and 8. The average follow-up was 5 years (3-8). The assessment of the results was based on the comparison of rotational abilities of both hips before and after the operation (in unilateral and bilateral deformities), as well as on individual complaints before and after the operation. In patients with unilateral deformity, their "healthy" hips were the control hips. The analysis of the femoral neck anteversion before and after operation was performed. RESULTS: Average values of medial and lateral rotation of the deformed hips before operation exhibited significant statistical difference when compared to control hips. The difference of average values of rotatory movements of control and operated hips was not statistically significant after operation. The difference of average preoperative values of the femoral neck anteversion in hips with deformity was statistically significant (49.40+/-4.63 degrees compared to 32.8+/-3.11 degrees ). Postoperative average values of anteversion in operated and control hips were not statistically significant. The difference between average preoperative (49.40+/-4.63 degrees ) and postoperative (35.80+/-7.66 degrees ) values of the femoral neck anteversion was statistically significant. Excellent results were achieved in 5 (50%) patients, i.e. 8 (53.3%) hips; good results were achieved in 3 (30%) patients, i.e. 5 (33.3%) hips; poor result in 2 (20%) patients, i.e. 2 (13.3%) hips. All 5 patients who had undergone surgery of both hips had symmetric outcome. Three patients had excellent results, while two had good results. Patients with excellent and good results (80% of patients, 86.6% of hips) showed neither weakening of the operated hip abduction nor pelvic instability (positive Trendelenburgh hip test). No complications were recorded postoperatively. CONCLUSION: Transposition of gluteal muscles can be recommended in patients under 10 years of age as there is still a chance for their femoral neck to change orientation, to decrease the anteversion and thus to achieve long-lasting effect. Fixation of transposed muscles by wire proved to be effective.

[Current diagnosis and treatment of the osteoarticular tuberculosis]. / Savremena dijagnostika i lecenje kostnosglobne tuberkuloze.

In 1993, tuberculosis was recognized as global medical problem by WHO. Recurring flare-up of this disease was triggered by difficult socioeconomic situation of the countries in transition, current development of immunocompromising diseases, and some other factors have contributed, too. The osteoarticular tuberculosis has been always postprimary and localized form of the disease, which, due to certain similarity to some other osteoarticular diseases, has been challenge for orthopaedic surgeons both from diagnostic and treatment aspects. Bacteriological diagnostics has had a limited value due to application of recommended tuberculostatic medication before obtaining specimens from bones or joints; and, on the other hand, rapid bacteriological methods, because of their expensive equipment, could be carried out in large mycobacteriology laboratories only. New visualizing methods, CT and MRI, have been particularly important for detection and monitoring of tuberculosis process in the spine during the early stage of the disease, what is impossible to achieve with native radiograms. Programmed administration of tuberculostatic drugs both in non-operative and surgical treatment has been proven necessary.