Comparison of the posterior approach versus the dorsal approach in the treatment of congenital vertical talus.

The purpose of this study was to compare retrospectively the results of a single-stage dorsal approach versus the posterior approach for the surgical treatment of congenital vertical talus (CVT) at a single institution. Twenty-four patients (33 feet) with CVT were treated surgically between 1960 and 1998. Eighteen patients (25 feet) underwent a posterior release (group 1), and six patients (eight feet) underwent surgery via the dorsal approach (group 2). All patients were evaluated at a minimal follow-up of 3 years. Preoperative and follow-up radiographs were evaluated, and a modified version of the clinical score by Adalaar was used. Group 1 had 45 procedures on 25 feet, whereas group 2 had no repeated or revision operations. The clinical score was 6.75 for group 1 and 8.0 for group 2. Tourniquet time was 123 minutes and 87 minutes for groups 1 and 2, respectively. Twelve group 1 patients (48%) had avascular necrosis (AVN) versus none of the group 2 patients. Both groups had similar preoperative and postoperative radiographic measurements. Both approaches were able to reduce successfully the talonavicular joint; however, the single-stage dorsal incision group required significantly less operative time, had better clinical scores, and had fewer complications 3 years after surgery.

Effect of clonidine on upper extremity tourniquet pain in healthy volunteers.

BACKGROUND AND OBJECTIVES: Tourniquet pain is often a limiting factor during intravenous regional anesthesia (IVRA). The purpose of this study was to evaluate the efficacy of 1 microg/kg of clonidine added to IVRA-lidocaine in decreasing the onset of severe tourniquet pain. METHODS: Upper extremity IVRA was performed in 15 volunteers with a double-cuffed tourniquet on 2 separate occasions at least 1 week apart. IVRA was established with either 40 mL 0.5% lidocaine (IVRA-L) or 40 mL 0.5% lidocaine with 1 microg/kg clonidine (IVRA-Cl). Verbal pain scores (VPS) from 0 to 10 were recorded every 5 minutes. When the VPS reached 6, the distal cuff was inflated, and the proximal cuff was deflated. This was defined as the first tourniquet time (T1). The study was terminated at a VPS of 10, or at 60 minutes, whichever occurred first. The time from distal cuff inflation to deflation was defined as the second tourniquet time (T2). Total tourniquet time (TT) was the sum of T1 and T2. RESULTS: T1 for IVRA-L (21.6 +/- 3.9) and IVRA-Cl (22.7 +/- 2.7) were not significantly different. T2 and TT were significantly longer (P < .0001; P < .0007, respectively) for IVRA-Cl (33.0 +/- 6.2; 55.6 +/- 6.6) than for IVRA-L (25.5 +/- 4.4; 47.1 +/- 5.2). CONCLUSION: This study shows that the addition of 1 microg/kg of clonidine to 40 mL of 0.5% IVRA-L delays the onset time of tourniquet pain in healthy, unsedated volunteers.

An examination of the knee function during gait in children with myelomeningocele.

In this retrospective study, 37 patients with myelomeningocele who had undergone gait analysis were examined. Patients were divided into groups based on the level of involvement (29 sides: L4; 26 sides: L5; 19 sides: S1-2). Results showed increased knee flexion and associated knee extensor moments with increasing level of neurologic involvement. The mean coronal plane knee position in stance was normal in all groups and not related to coronal plane knee moment. However, there was an increased incidence of a net knee adductor moment in stance with increasing involvement (mean, 0.02 +/-0.18 N.m/kg for the L4 group). The presence of a visual valgus thrust based on video records was not reliable in predicting an abnormal knee coronal plane moment. An abnormal knee adductor moment in stance was most highly related to coronal plane trunk motion (r = -0.62) and not tibial torsion (r = -0.340). Increased transverse plane range of motion of the knee was most highly related to transverse plane trunk motion (r = 0.67).

Salvage of open tibial fracture with segmental loss of tibial nerve: case report and review of the literature.

We report a case history, treatment, and follow-up of an open comminuted distal tibial fracture with significant soft tissue loss and segmental loss of the tibial nerve and posterior tibial artery. This constellation of injuries with an insensate plantar foot has often been an indication for amputation. In this instance, a functional distal extremity was salvaged with the use of Ilizarov fixation, delayed primary tibial nerve cable grafting, and staged soft tissue coverage. Clinical follow-up and review of the literature on the techniques used are offered for consideration.

The effects of ankle-foot orthoses on the ankle and knee in persons with myelomeningocele: an evaluation using three-dimensional gait analysis.

The purpose of this study was to determine the effects of the ankle-foot orthosis (AFO) on gait patterns in patients with low-level myelomeningocele and to identify any abnormal gait patterns that may lead to future knee instability and pain. A total of 28 children (26 L4-level sides, 18 L5-level sides, and 10 S1-2-level sides) underwent a three-dimensional gait analysis when ambulating barefoot and with AFOs. Results show significant improvements in sagittal plane function with reductions in excessive ankle dorsiflexion, increases in peak plantar flexor moment, and reductions in crouch and knee extensor moment in the L4 and L5 groups. The only improvement in the S1-2 group was a reduction in excessive dorsiflexion, but there was a reduction in power generation at the ankle. The S1-2 group had normal transverse plane knee motion in stance during barefoot walking that increased significantly (p < 0.01) with the AFO. Both the L5 and L4 groups showed greater-than-normal transverse plane knee motion in stance during barefoot walking that also increased significantly (p < 0.01) with the AFO. The results suggest that excessive knee transverse plane rotation may contribute to knee instability more than coronal plane abnormalities. The AFO in S1-2-level patients may be more detrimental for the knee than barefoot walking.

Effect of hamstring and psoas lengthening on pelvic tilt in patients with spastic diplegic cerebral palsy.

The purpose of this study was to evaluate the effects of hamstring lengthenings and psoas recessions over the brim of the pelvis (OTB) on pelvic function in the gait of patients with spastic cerebral palsy. Seventy-three patients were divided into four groups based on surgical intervention: medial hamstrings (n = 37), medial and lateral hamstrings (n = 12), medial hamstrings with psoas OTB (n = 9), and medial and lateral hamstrings with psoas OTB (n = 15). Three-dimensional gait analysis was completed both before and approximately 1 year after surgery. When pelvic position in gait was normal or posterior of normal preoperatively, there was a significant increase in pelvic tilt (p < 0.05) when medial and lateral hamstrings were lengthened, irrespective of simultaneous psoas OTB surgery. Medial hamstrings alone, with or without simultaneous psoas OTB, did not result in a significant change in pelvic position, irrespective of preoperative pelvic position. The only surgical combination that caused a reduction in excessive preoperative anterior pelvic tilt was medial and lateral hamstrings with psoas OTB, a 4 degrees change of limited clinical significance. In general, psoas and medial hamstring surgery have minimal effect on the pelvic position during gait. Medial and lateral hamstring lengthening will increase pelvic tilt if preoperative pelvic position is normal or slightly posteriorly tilted. The results of this study suggest that the fundamental determinants of pelvic position during gait postoperatively are the extent of hamstring surgery (medial only vs. both medial and lateral hamstring lengthening) and the preoperative position of the pelvis.

Effect of shoe color on shoe temperature and potential solar injury to the insensate foot.

The authors compared shoes of different colors in terms of the amount by which their temperature increased when subjected to radiant heat. Three trials of temperature measurements were performed for white and black leather walking shoes. A balloon filled with water was placed in the shoe and the surface temperature of the balloon was measured at baseline and after the shoe had been exposed to an infrared heat lamp for 15- and 30-minute periods. The results were significant: The mean increase in temperature after 15 minutes of exposure was between 4.0 degrees F and 8.8 degrees F greater in the black shoe than in the white shoe. After 30 minutes of exposure, the mean increase in temperature was between 7.8 degrees F and 13.6 degrees F greater in the black shoe than in the white shoe. This information can help prevent thermal injury to the insensate foot when shoes are worn in the sun for a prolonged period. Brief case reports of three patients who experienced such thermal injury are presented.

Early innominate osteotomy as a treatment for avascular necrosis complicating developmental hip dysplasia.

The clinical and radiographic outcomes of 25 patients with avascular necrosis (AVN) of the femoral head complicating developmental hip dysplasia (DDH) were analyzed. Seven patients (group A) had an innominate osteotomy 1-3 years after the ischemic insult. Eight patients (group B) had a pelvic osteotomy between 5 and 10 years after the insult, and 10 patients (group C) did not have a pelvic osteotomy. The minimum follow-up period was 10 years from the time of the ischemic insult. The hips in group A patients (early osteotomy) showed significantly better radiographic outcomes as assessed by a modified Severin grading. These patients also had less pain, fewer gait disturbances, and required fewer additional procedures for limb length discrepancy or greater trochanteric overgrowth.

Alterations in surgical decision making in patients with cerebral palsy based on three-dimensional gait analysis.

The purpose of this study was to compare surgical recommendations made by clinicians experienced in gait analysis when using information provided from the clinical examination and videotape, with recommendations made after the addition of kinematic, kinetic, and electromyographic (EMG) data. Ninety-one patients with a diagnosis of cerebral palsy were seen in the gait laboratory as part of the surgical decision-making process. Experienced clinicians reviewed video and clinical examination data for each patient and made surgical recommendations. Joint kinematics and kinetics and EMG data were then reviewed, and a second set of surgical recommendations was made. Comparisons between these recommendations showed that the addition of gait-analysis data resulted in changes in surgical recommendations in 52% of the patients, with an associated reduction in cost of surgery, not to mention the human impact of an inappropriate surgical decision, which is more likely without gait analysis. When changes in recommendations were made, an increase in surgical recommendations was observed for the gastrocnemius (59%) and rectus femoris (65%), whereas decreases were observed for the hamstrings (61%), psoas (78%), hip adductors (83%), femur (86%), and tibia (64%).

The musculoskeletal management of children with cerebral palsy.

Orthopedic management of children with cerebral palsy is best accomplished with a team approach, which generally is effective in the other neuromotor disabilities of childhood, such as myelomeningocele and muscle disease. Because contracture development is inevitable in growing children with spastic musculature or muscle imbalance and is a prime cause of musculoskeletal dysfunction, its control over time using therapy, bracing, and medication is essential. Problems such as severe contracture, joint deformity, and scoliosis interfere with the basic requirement of comfortable seating in children with quadriplegic involvement and frequently require surgery. In ambulatory children, the use of three-dimensional gait analysis has allowed multilevel surgery to be appropriately planned, minimizing exposure to surgery and therapy.

An evaluation of the posterior leaf spring orthosis using joint kinematics and kinetics.

The primary function of the posterior leaf spring orthosis (PLS) is to prevent excessive equinus or drop foot in swing. The name of the orthosis, posterior leaf "spring," suggests that it also mechanically augments push-off in stance. The purpose of this study was to determine the effect of the PLS on ankle function by using computerized gait-analysis techniques. Multiple barefoot versus brace walks were compared in 31 children with cerebral palsy. Results indicate that the PLS reduces excessive equinus in swing and is sufficiently flexible to allow ankle dorsiflexion in midstance. In terminal stance, the peak power-generating capabilities of the ankle were reduced when the child was wearing the PLS. Energy results indicate that more mechanical energy was absorbed during midstance and less produced during terminal stance with the PLS. Therefore, the PLS improved ankle function but did not augment ankle function through storage and return of mechanical, or spring, energy.

Differential diagnosis in physical therapy evaluation of thigh pain in an adolescent boy.

Slipped capital femoral epiphysis (SCFE) is a condition of the adolescent hip in which the femoral head displaces relative to the femoral neck. This disorder is characterized by a synovitis of the hip joint or a mechanical limitation of motion with pain referred to the thigh or knee. The case described in this report is typical of an adolescent with SCFE. A brief review of epidemiology, etiology, clinical presentation, and treatment is presented to facilitate the physical therapist's knowledge of this condition and its proper management. Delay in diagnosis and treatment of SCFE may result in progression of the slip and chronic disability from osteoarthritis. It is imperative, therefore, that a patient suspected of having this condition be promptly referred to an orthopaedic surgeon for radiographic evaluation.

Pelvic osteotomies for subluxation of the hip in cerebral palsy.

Twenty-three pelvic osteotomies (10 Salter, seven Chiari, six Steel) were performed on 21 patients with cerebral palsy for hip subluxation or dislocation from 1977 to 1986. The principal indication for osteotomy was inadequate coverage of the femoral head. Stability was maintained in 19 of 23 hips with an average follow-up of 6.14 years (2.0-13.3). The hips showed a significantly improved center-edge angle, acetabular angle, Reimers index, and neck-shaft angle. There were six failures; painful degenerative joint disease developed in two patients and resubluxation or dislocation in four. Pelvic osteotomies can provide hip stability in selected cerebral palsy patients.

Preliminary traction in the treatment of developmental dislocation of the hip.

The benefit of preliminary traction in the treatment of developmental dislocation of the hip has not been clearly demonstrated. We retrospectively analyzed the results of traction treatment of 90 dislocated hips in 72 patients. After a 3-week course of traction, patients underwent attempted closed reduction. Fifty-two hips (58%) were managed successfully by closed reduction, whereas 38 hips (42%) required primary open reduction. chi 2 analysis revealed no significant difference in either the rate of successful closed reduction or the incidence of avascular necrosis compared to recently published series in which preliminary traction was not used. On the basis of presentation radiographs and arthrograms, we were unable to identify a subgroup of patients that clearly benefited from the use of traction in the treatment of developmental dislocation of the hip.

Intertrochanteric versus supracondylar osteotomy for severe femoral anteversion.

Severe femoral anteversion may require operative correction if it results in cosmetic or functional disability. Complication rates < or = 15% have been reported after derotational osteotomy. We report the results of 51 osteotomies in 27 patients with idiopathic femoral anteversion over a 15-year period at a major pediatric orthopaedic referral center. Thirty-four derotational osteotomies in 17 patients were performed using a supracondylar technique with crossed-pin fixation. There was a 14.7% complication rate. Sixteen osteotomies in 10 patients were performed using an intertrochanteric osteotomy and blade-plate fixation with the patient in the prone position; there were no reported complications. The intertrochanteric osteotomy allowed more accurate correction of the intoeing deformity and decreased the need for postoperative immobilization. In addition, the more secure blade-plate fixation benefits the active child > 8 years of age who requires operative correction of severe femoral anteversion.

Kinematic and kinetic evaluation of the ankle after lengthening of the gastrocnemius fascia in children with cerebral palsy.

The effect of surgical lengthening of the gastrocnemius fascia on ankle joint kinematics and kinetics during gait in patients with cerebral palsy (CP) was evaluated. Twenty independent ambulators (24 sides) were included in this retrospective study. The evaluation included clinical examination, calculation of joint kinematics and kinetics, and collection of surface electromyography (EMG) during gait. Postoperative improvements were noted in static heelcord range of motion (ROM), with an associated increase in dorsiflexion in stance and swing. Kinetic analysis showed a decrease in the abnormal energy generated around the ankle in midstance and a statistically significant increase in the energy generated in late stance for push-off.

Heterotopic ossification after rhizotomy and femoral osteotomy.

In 15 patients with cerebral palsy who underwent selective posterior rhizotomy (SPR) and subsequent proximal femoral varus derotation osteotomy (VDO), heterotopic ossification (HO) around the hip after VDO was noted in four of eight patients with spastic quadriplegia (seven of 26 hips, 27%). HO was not noted in the seven patients with spastic diplegia. A radiographic review of 118 hips with a femoral VDO in the 69 patients with cerebral palsy who did not undergo SPR during the same period showed no HO. Frequent evaluation of postrhizotomy patients with cerebral palsy quadriplegia after a femoral VDO is necessary to recognize HO as a possible etiology for late-onset pain and limited hip range of motion (ROM).

Rectus femoris surgery in children with cerebral palsy. Part I: The effect of rectus femoris transfer location on knee motion.

Rectus femoris transfer was performed in 78 children (105 sides) with cerebral palsy (CP) at the same time as other surgical procedures as appropriate. The transfer was either medial to the sartorius (62 sides), semitendinosus (19 sides), or the gracilis (14 sides) muscles, or laterally to the iliotibial band (10 sides). Gait analysis performed before and 1 year after operation demonstrated increased knee range of motion (ROM) with increased extension at initial contact and in midstance and maintained knee flexion in swing. There were no statistically significant differences between the four transfer sites in the effect on those variables. Therefore, the choice of rectus femoris transfer site can be dictated by surgical preference or by the nature of other simultaneous procedures. There was no consistent change in transverse plane motion of the hip or foot progression angles between the two gait analyses, suggesting that rectus femoris transfer does not affect gait abnormalities observed in the transverse plane.