Myelomeningocele at the sacral level. Long-term outcomes in adults.

We reviewed the long-term outcome of thirty-six patients who had a myelomeningocele at the sacral level and whose average age was twenty-nine years (range, nineteen to fifty-one years). The patients were followed at our institution for an average of ten years (range, one to thirty-three years); however, the medical records from birth on were available for all of the patients. Instead of the expected outcome that function had been maintained in this group of patients, we found a decline in the ability to walk of eleven of the thirty-five patients who had been community ambulators initially. At the time of the most recent follow-up examination, five had become household ambulators, two were non-functional ambulators, and four were non-ambulators. The one patient who initially had been a household ambulator was a non-ambulator at the time of the most recent follow-up examination. A decrease in plantar flexion was found in fourteen patients and a decrease in plantar sensation, in fifteen. Breakdown of the skin and soft-tissue infections on the plantar surface of the metatarsal heads and of the heel were seen in twenty-seven and twenty-three patients, respectively, and were related to the absence of plantar sensation. Fifteen patients had osteomyelitis involving the lower extremity. Eleven patients had had a total of fourteen amputations: five involved one toe or more, four involved one ray or more, two were Syme amputations, and three were below-the-knee amputations. By the most recent follow-up examination, thirty-three patients had had a total of 371 orthopaedic procedures. The procedures included tendinous procedures; osteotomies; soft-tissue releases, transfers, and débridements; amputations; and arthrodeses of the lower extremities or spine.

Equinovarus deformity in arthrogryposis and myelomeningocele: evaluation of primary talectomy.

As initial surgical management for rigid equinovarus deformities, 16 children with arthrogryposis (30 involved feet) and 16 myelodysplastic children (26 involved feet) underwent primary talectomies or extensive posterior-medial releases (PMR). When compared with primary PMRs in arthrogrypotic children, primary talectomies revealed a greater number of good and fair results, decreased recurrence rates, less procedures per foot, and maintenance of ambulatory status. Recurrent forefoot and cavus deformities were present after primary talectomies. Primary talectomy in arthrogrypotic children was more effective than posterior-medial releases or secondary (salvage) talectomy. Because of the small number of feet involved, the role of primary talectomy in myelomeningocele was not clarified by this study. Radical PMRs in myelodysplastic children resulted in a significant number of hindfoot valgus deformities that required secondary procedures.

Review of the Girdlestone-Taylor procedure for clawtoes in myelodysplasia.

To clarify the role the flexor tendon to extensor hood transfer (Girdlestone-Taylor procedure) may have in correction of clawtoes in myelodysplasia, 20 patients with residual paralysis from myelomeningocele who underwent the procedure between 1976 and 1985 were reviewed. They were evaluated for the effectiveness of the procedure and occurrence of late deformities. A total of 25 feet with 65 toes were evaluated in patients ranging in age from 0.6 to 38.8 years. Results were classified as good if toes were straight, fair if mild deformity was present, and poor if definite clawing was noted. The overall results showed 60% good, 34% fair, and 6% poor results. Toes followed less than 24 months had more good results than those with longer follow-up. There was little difference in the results between great toes and lesser toes. No serious complications occurred. Our results indicate a sufficient level of success to utilize this method for correction of flexible claw toe deformities without resorting to bony procedures. We suggest this should be particularly useful in children.

Team up for success: a CEO & board chairman discuss the ties that bind.

As the health care delivery system faces increasingly complex issues and changes, the need for an amicable, productive working relationship between the governing board and the administrator grows in importance. Both the chairman of the board and the administrator of a California hospital give their perspective on how they view their own and each other's roles, and the factors that have been decisive in the development of a mutually supportive working relationship.

Energy cost of walking and of wheelchair propulsion by children with myelodysplasia: comparison with normal children.

The oxygen consumption of 15 myelodysplastic children during walking and propelling a wheelchair was studied. In comparison to normal children, they walked more slower and consumed more oxygen per meter, but had a similar rate of oxygen consumption. A swing-through gait pattern was 33 per cent more energy-efficient than a four-point gait pattern for these children. Wheelchair propulsion produced velocities and energy efficiencies similar to normal children walking. Oxygen consumption and velocity measurements were found to be significantly related to the clinical factors of level of lesion and strength of hip and knee extension. Regression lines and equations are presented to permit prediction of energy cost and efficiency from heart-rate data of myelodysplastic children.

Selection of appropriate treatment for patients with myelomeningocele.

Patients with myelomeningocele are limited in their eventual adult habilitation by the level of their lesion. Patients with high level lesions are not only limited in their motor skills but tend to have an increased number of central nervous system abnormalities in relationship to the height of their level of paralysis. These disabilities require more treatment and training, and the patient's time should not be occupied by unnecessary treatment or training that will not be utilized in adulthood. Exhaustive treatment for ambulation should not be utilized in potentially nonambulatory patients. Early prognostic indicators are utilized and treatment is based on the patient's potentials. Teaching and practice of the skills needed in adulthood along with motivation impetus must be carried out in the young child if the skills are to be successfully used in adulthood.

Surgery of the hip in myelomeningocele as related to adult goals.

This article summarizes our overall principles of orthopedic treatment of the hip and the basis for these principles. We hope our young patients with undergo fewer operative procedures, spend less time in the hospital, and be better adapted for their adult lives. This will be accomplished by better prognosis of their adult abilities and by treating the problems related to those objectives, not their X-rays or transient childhood goals.

The effect of hip reduction on function in patients with myelomeningocele. Potential gains and hazards of surgical treatment.

We studied seventy-six patients with myelomeningocele who were more than five years old and ahd had no hip surgery during the two previous years. Of these seventy-six patients, forty-one had had no operative treatment intended to reduce the dislocation of their hips and thirty-five had been operated on one or more times to reduce or maintain reduction of one or both hips. The presence of the femoral head in the acetabulum did not improve range of hip motion or ability to walk, nor did it reduce the amount of bracing required or decrease pain. The complications of surgical treatment to gain reduction were numerous and included failure to obtain stability in 40 per cent of the hips, loss of hip motion, and fractures. A level pelvis and a good range of hip motion were found to be more important for function than reduction of the hips. The goal of treatment should be maximum function, not roentgenographic reduction of the dislocated hip.