Transphyseal osteotomy of the distal tibia for correction of valgus/varus deformities of the ankle.

This study is a retrospective review of the results of consecutive cases of a transphyseal osteotomy of the distal tibia. Indications for the procedure are significant valgus or varus deformities of the ankle needing acute correction because of problems with the skin and brace fit as well as progressive deformity. Twenty-one patients with a variety of underlying diagnoses, five with bilateral deformities, underwent this procedure. The technique involved making either a medially based closing or opening wedge with the distal limb of the osteotomy through the physis or the physeal scar so that it was very close to the ankle joint. A fibular osteotomy was not necessary except in three ankles. All osteotomies healed. All patients were able to ambulate and use their braces as soon as their osteotomies healed, and none had any further pressure sores or brace-related problems, although some had mild residual valgus or varus deformities. There were no significant leg-length discrepancy problems as a result of the surgery. This osteotomy is a treatment alternative for significant angular deformities of the ankle that require acute correction.

Regional fasciocutaneous flap closure for clubfoot surgery.

Skin closure after a comprehensive posteromediallateral release of clubfeet through a Cincinnati incision may be difficult. This is especially true for cases of severe deformity either primary or recurrent. To deal with this, certain techniques have been developed. These consist of casting the foot in an undercorrected position with subsequent serial cast changes, leaving the incision completely or partially open for closure by secondary intention, using tissue expanders, and using different flap techniques. Five patients with nine clubfoot deformities who were treated with a comprehensive posteromedial-lateral release through a Cincinnati incision and underwent fasciocutaneous flap closure since June 1998 were included in this study. These flaps allowed correction and complete wound closure at the end of surgery without any skin tension. These flaps were constructed either in a rotational or V-Y advancement manner. None of the patients had any major complications. In summary, this new fasciocutaneous flap is a simple and reliable method in cases with primary skin-closure difficulties. It does not require special equipment or a plastic surgeon.

Lower extremity compartment syndrome in an adolescent with spinal cord injury.

OBJECTIVE: Describe the unusual complication of lower extremity compartment syndrome occurring in an adolescent with spinal cord injury (SCI). METHODS: Case presentation. RESULTS: A 17-year-old male with C5 ASIA A complete SCI developed a compartment syndrome of his lower leg on the ninth day postinjury. Presenting signs included an equinus deformity of the foot, blackened induration over the anterior tibia, circumferential erythematous markings over the calf, large urticarial lesions over the knee, and calf swelling. The presumed etiology of the compartment syndrome was excessive pressure from elastic wraps, which were placed over gradient elastic stockings. Pressures were 51 mmHg in the superficial posterior, 50 mmHg in the deep posterior, 33 mmHg in the anterior, and 34 mmHg in the peroneal compartments. The patient also developed rhabdomyolysis with myoglobinuria. In addition to supportive care, the patient underwent a dual incision fasciotomy for compartment release. CONCLUSIONS: The development of lower extremity compartment syndrome was probably a result of excessive pressure applied by elastic wraps. Elastic wraps should be used with caution in individuals with SCI.

The halo-Milwaukee brace. Case series of a revived technique.

STUDY DESIGN: A case series in which the halo-Milwaukee brace was used for postoperative immobilization in children with complex congenital and developmental spinal deformities. OBJECTIVES: To describe the use of halo-Milwaukee orthosis in a pediatric population for stabilization of the cervical and upper thoracic spine. SUMMARY AND BACKGROUND DATA: Postoperative immobilization of the neck and upper thorax can be achieved with cervical orthoses, cervicothoracic lumbar orthosis, halo cast, Minerva jacket, or halo vest. In the young child or in individuals with severe deformities, prefabricated braces often do not provide adequate stability or predictable fit. The halo-Milwaukee brace has proven to be an effective and versatile technique in the management of complex pediatric spinal deformities. METHODS: Halo-Milwaukee brace immobilization was used in 12 patients after surgical stabilization of the upper thoracic or cervical spine. Technique and indications are discussed in this report. Surgical outcomes and complications were reviewed retrospectively in all cases. RESULTS: Application of the halo-Milwaukee brace was a clinically effective and safe means of controlling the upper thoracic and cervical spine. The orthosis was well tolerated and allowed access to the posterior incision. The brace is easily converted to a standard Milwaukee brace with neck ring. The pelvic segment of the brace is molded before surgery, and in most instances did not require postoperative modification. CONCLUSION: The halo-Milwaukee brace is a simple and convenient method of intraoperative and postoperative immobilization. The technique is applicable in patients who cannot be treated with more conventional off-the-shelf orthoses. The brace was well tolerated and allowed for early patient mobilization.

Simultaneous ipsilateral femoral and tibial lengthening with the Ilizarov method.

Eight pediatric patients who underwent nine simultaneous ipsilateral femoral and tibial lengthenings with the Ilizarov external fixator were reviewed. The patient's demographics, diagnoses, corticotomy levels, mechanical axes, healing indices, amounts of lengthening, and complications were recorded. The patients' average age was 8 years 10 months (5 years 4 months-15 years 10 months) with an average follow-up of 49 months (30-88 months). The percentage of femoral lengthening averaged 16.7% (8-23%) with an average healing index of 28 days/cm (20-38 days/cm). The percentage of tibial lengthening averaged 18% (9.6-23.6%) with an average healing index of 29 days/cm (1940 days/cm). Four complications in three patients occurred as a direct result of the lengthening process. Three of the complications involved soft-tissue contractures, which were each successfully treated with one additional surgical procedure, whereas the fourth complication involved poor bone regeneration and required bone grafting and additional immobilization.

Long-term outcomes and life satisfaction of adults who had pediatric spinal cord injuries.

OBJECTIVE: To determine long-term outcomes and life satisfaction of adults who sustained pediatric spinal cord injury (SCI). DESIGN: Structured interview of adults who were 25 years or older who had pediatric SCI. SETTING: Community. PARTICIPANTS: A convenience sample of 46 patients from a total of 81 patients who received care in an SCI program: 1 refused participation, 4 died, and 30 were lost to follow-up. MAIN OUTCOME MEASURES: A structured questionnaire including physical, psychosocial, and medical information. The Craig Handicap Assessment and Reporting Technique and two measures of life satisfaction were also administered. RESULTS: Participants were 25 to 34 years old, mean 27 years. Thirty-two had tetraplegia and 14 had paraplegia. Thirty-one were men. Mean years of education was 14. Fifty-four percent were employed, 48% lived independently, and 15% were married. Life satisfaction was associated with education, income, satisfaction with employment, and social/recreation opportunities, and was inversely associated with some medical complications. Life satisfaction was not significantly associated with level of injury, age at injury, or duration of injury. CONCLUSIONS: Individuals who had pediatric SCI, much like adult-onset SCI, have the greatest opportunity for a satisfying adult life if rehabilitation emphasizes psychosocial factors such as education, employment, and long-term health management.

Cervical spine fusion: not protective of cervical spine injury and tetraplegia.

The occurrence of tetraplegic spinal cord injuries in two patients who had preexisting cervical spine fusions highlights the vulnerable nature of such patients. One patient sustained a C5-6 fracture-dislocation after a motor vehicle accident, despite a spontaneously fused cervical spine as a consequence of his juvenile rheumatoid arthritis. A second patient sustained a C3-4 distraction injury in a sporting injury 2 years after he had undergone a posterior cervical spine fusion because of an aneurysmal bone cyst. Prior to their spinal cord injuries, both patients had no apparent neurologic deficits, were relatively active, and followed no specific precautions for their spines.

Supramalleolar osteotomy for ankle valgus in myelomeningocele.

Fifty-five supramalleolar osteotomies were performed in 35 patients for progressive hindfoot valgus in myelomeningocele. All patients were ambulatory. The most common motor level of innervation was L3 in 42 limbs. The average age at surgery was 12 years. The average follow-up was 8 years. Preoperatively, all patients experienced progressive difficulty with brace use, and anteroposterior weight-bearing ankle radiographs showed a valgus tilt of the talotibial angle (TTA) of > or = 10 degrees with an average of 18 degrees. The average postoperative correction of TTA was 17 degrees. The results were graded as follows: excellent, 42 limbs; good, eight limbs; fair, three limbs; and poor, two limbs. The fair and poor limb results were the result of loss of correction or nonunion. The best results were seen when the TTA was corrected to 5 degrees of varus.

Neurologic and vascular complications of scoliosis surgery in patients with Ehlers-Danlos syndrome. A case report.

STUDY DESIGN: Case reports. OBJECTIVES: Description of neurologic and vascular complications of scoliosis surgery to children and adolescents with ehlers-danios syndrome. SUMMARY OF BACKGROUND DATA: There have been no previous reports of neurologic and vascular complications of scoliosis surgery in patients with Ehlers-Danlos syndrome. Scoliosis and vascular fragility are characteristics of certain types of Ehlers-Danlos syndrome. METHODS: Case reports and literature review. RESULTS: Subsequent to scoliosis surgery, three patients with Ehlers-Danlos syndrome developed neurologic complications: two developed paraplegia, and one developed unilateral foot and ankle weakness with transient neurogenic bladder. Another patient with Ehlers-Danlos syndrome experienced avulsion of segmental arteries during anterior spinal surgery. CONCLUSIONS: Patients with Ehlers-Danlos syndrome may be at high risk for neurologic and vascular complications consequent to scoliosis surgery, necessitating careful perioperative evaluation and management.

Anatomic considerations of the foot and leg in tibial hemimelia.

Five lower extremities from four patients with tibial hemimelia were available for dissection. Multiple tendon anomalies were present. The ankle articulation was found to have a nonfunctional uniplanar motion. Multiple coalitions of the osseous structures of the foot were found, with subtalar coalition the most common.

Arthrographic evaluation of developmental dysplasia of the hip. Outcome prediction.

Arthrograms of 35 hips in 33 children less than 2 years of age with typical development dysplasia of the hip were reviewed. After arthrograms were repeated for 11 hips 6 weeks following the initial test, results were classified into 6 types based on medial pooling ratio and morphology of the acetabular limbus. Using modified Severin's criteria for outcome evaluation, 7 of the 11 hips had been upgraded in type. All hips that were classified as Type I by arthrogram had Severin I results. The relation of arthrographic type and radiographic results was statistically significant. Immediate open reduction is recommended in hips classified as Type VI at first arthrogram or Type III and above at repeat arthrogram.

Chondrolysis and avascular necrosis: complications of slipped capital femoral epiphysis.

Chondrolysis and avascular necrosis (AVN) are serious complications after slipped capital femoral epiphysis (SCFE). Chondrolysis, or acute cartilage necrosis of the capital femoral epiphysis, can occur in treated and untreated SCFE. Its exact etiology has not been conclusively determined, and there may be some connection with hardware penetration into the joint and its development. Because chondrolysis can occur in both treated and untreated hips, an immune mechanism has been postulated. Although some evidence of immune reaction has been confirmed in the joint, no screening test has yet been developed to determine susceptible individuals. AVN is clearly related to impeded blood supply to the femoral head and to severely slipped unstable acute slips. Forceful reduction of the femoral head must be avoided. However, some slips are so unstable that reductions occur merely with positioning of the patient for operation. Improperly placed fixation devices may also play a role in the development of AVN. Chondrolysis and AVN may not be completely avoidable in the treatment of SCFE.

Ambulation with parapodia and reciprocating gait orthoses in pediatric spinal cord injury.

The use of parapodia and reciprocating gait orthoses (RGOs) was reviewed in 41 children and adolescents with spinal cord injuries. Compared with users of RGOs, users of parapodia were younger when injured and when the orthotic was first used, were more likely to be household ambulators and to have higher neurological levels, and were unlikely to continue their use of the parapodium after early school age. Hip contractures that required surgical releases or contributed to discontinuation of orthotic usage were present in six of 26 parapodium users and 12 of 22 RGO users. RGOs and parapodia have a limited but important role in management of pediatric spinal cord injury, and should be used in a developmentally based program responsive to the changing needs of children and adolescents.