Gait asymmetry in patients with limb length discrepancy.

Foot loading patterns and neuromuscular function of both limbs during walking were investigated on 25 patients with limb length discrepancy. Plantar pressures and 2-D ground reaction forces were recorded simultaneously with electromyographic activities at two different walking speeds. Bilateral comparison indicated that moderate limb length discrepancies resulted in asymmetrical gait patterns. The duration of the stance phase was reduced in the short limb in both walking speeds. The vertical ground reaction force (F) in the push-off phase was greater in the long limb both at normal (1.33 (SO, 0.05 BW) vs. 1.29 (SD, 0.09 BW)) (P=0.0027) and fast walking speed (1.55 (SD, 0.11) vs. 1.48 (SD, 0.15 BW)) (P=0.001). Peak plantar pressures were higher under the big toe in the long leg and the heel-off occurred faster. The push-off phase was initiated earlier in the short leg. The maximum isometric torque of the long limb was considerably greater (673 Nm vs. 239 Nm) (P=0.026). The results imply that the loading of the long limb is greater and the foot loading patterns shifted more to the forefoot in the long, limb to compensate walking disturbances caused by limb length discrepancies.

Arthrogryposis multiplex congenita: perinatal and electromyographic findings, disability, and psychosocial outcome.

Fifty-two patients with arthrogryposis multiplex congenita were followed up for 1 to 36 years. There were six twin pregnancies, and delivery was complicated by breech position in 16 cases. In 19 cases the cause was atrophy of the alpha motoneurons of the spinal cord, detected by electromyography. Six patients did not achieve walking ability. Severe disability for other reasons was noted in two patients who had bilateral rigid extension contractures of the elbows and in six patients whose spinal deformities interfered with the balance of the trunk. Treatment of flexion contractures of the hips and knees seemed to be important in case it promotes the walking ability. Spinal deformities interfering with the balance of the trunk should be treated operatively. Restoration of elbow flexion was the main goal in operative treatment of the upper extremities. The intelligence of the patients was slightly above normal. The psychological analysis revealed significant diverging features compared with average population in testing situation. Socially the patients seemed to cope well.

[Hip in arthrogryposis multiplex congenita]. / La hanche dans l'arthrogrypose multiple congénitale.

PURPOSE OF THE STUDY: In arthrogryposis Multiplex Congenita (AMC) multiple joint contractures and deformities are present. Hips are often affected. In this follow-up study the outcome after primary treatment and secondary surgical procedures was analyzed with clinical and radiological features. MATERIAL AND METHODS: 52 patients with AMC were treated at Children's Hospital, Helsinki. 34 patients had Hip joint involvement. The most common type of Hip joint involvement was a flexion contracture (40 per cent). Thirty-five per cent of patients had rigid dislocations. Ten hips with rigid dislocations and four hips with flexion contractures was primarily operated on. Two failures of the primary operative procedures were noted. Thirty-one dislocated hips were treated non-operatively. RESULTS: In fourteen cases, reduction could not be achieved. Nineteen delayed surgical procedures were done. Acetabuloplasty was made in 6 hips, femoral osteotomy in 8 hips and total hip replacement in 3 hips. Aseptic necrosis of the femoral head encountered for 4 poor results in two cases of acetabuloplasty and 3 hips had a poor range of motion. In flexion contractures of the hips, 6 corrective osteotomies were done and in four cases the results were good. In all cases of total hip replacement the results were good and no complications were seen. DISCUSSION: The inefficiency to achieve reduction of dislocated hips in AMC-patients by conservative methods was confirmed in this study. Although it has been claimed that the majority of patients with flexion contractures can be managed by conservative treatment there were ten patients in this series who did not respond to this form of treatment. CONCLUSION: The primary form of treatment should be operative. Only in selected cases with bilateral dislocations should it be considered to leave the hips untreated. Double femoral osteotomy in recurrent flexion contractures or resistant flexion contractures and total hip replacement in adult patients with hip dislocations are useful methods.

Foot deformities in arthrogryposis multiplex congenita.

Foot deformities are common in arthrogryposis multiplex congenita. In this group of 52 patients with this diagnosis, 43 had foot deformities. The involvement was bilateral in all cases, and the most common type of deformity was talipes equinovarus (72 feet). The primary treatment in 52 of these patients was operative. Brockmann's procedure was the preferred method during the earlier years and posteromedial or posteromedioplantar release since 1974. Recurrences of the deformity are common; 36 operative procedures were done in 15 feet for recurrence of talipes equinovarus. The primary operative treatment should be extensive enough to correct all components of the deformity. Knee and hip deformity will often influence the outcome. Knee deformities especially cause problems in retaining the desired position of the feet. Talectomy and bone decancellations both seem to be effective in treating recurrences.

Muscle ultrasonography in arthrogryposis. Comparison with clinical, neuromyographic and histologic findings in 41 cases.

We studied the ultrasonographic appearance of muscles in 41 patients with arthrogryposis multiplex congenita (AMC). The observations were compared to the findings in clinical testing, electroneuromyography, and histological examination. The strength of the muscles in AMC-patients did not always correspond to the ultrasonographic morphology of the muscles. In extension contractures of the elbow and in equinovarus adductus deformities of the foot there was a distribution of pathological changes in the muscles corresponding to the primary deformity. The sound transfer through the muscles was decreased, notably in the neurogenic form of AMC. Ultrasonography is an important complement to the clinical examination and it should always be done prior to surgery and muscle biopsy.

Absorbable polyglycolide pins in internal fixation of fractures in children.

Absorbable implants made of synthetic biodegradable polymers were recently introduced clinically in internal fixation of fractures. In this prospective study of 71 pediatric patients with a variety of displaced physeal or nonphyseal fractures, self-reinforced polyglycolide pins 1.5 or 2.0 mm in diameter were used instead of Kirschner wires to fix the fragments. The majority of patients (45 children) had a fracture affecting the distal humerus. Mean age of the patients was 9.8 years (range 2-15 years). Follow-up averaged 15.8 months. In 62 patients (87%), an exact reduction of the fracture could be maintained until union. Among the remaining patients, six had minor inaccuracies or redisplacements of the fracture position, but in three patients with supracondylar fractures of the humerus breakage of the pins resulted in a severe redisplacement that necessitated a change in treatment method. With the exception of supracondylar fractures of the humerus, these preliminary results of polyglycolide pin fixation were deemed satisfactory. The fundamental advantage of this method is that no hardware removal procedures are required.

Mechanical failures of internal fixation in T and Y fractures of the distal humerus.

To evaluate the factors resulting in mechanical failures of internal fixation of distal T-type and Y-type humeral fractures, we reviewed the clinical course and final results in 61 consecutive cases treated with AO-ASIF internal fixation devices. The patients were followed for at least 2 years (range, 2-11 years). Mechanical failure occurred in 18 cases (29.5%). In 12 patients this resulted from an unstable fixation. Severe osteoporosis was present in four patients. In two patients no specific causative factor could be detected. A second osteosynthesis was undertaken in five patients, and four additional patients were later operated on for nonunion. The functional outcome after these mechanical failures was, unexpectedly, poor in only 6 of the 18 patients. In spite of this comforting finding, the conclusion is that to minimize the failure rate in the management of these demanding fractures strict adherence to the correct technical fixation principles is mandatory, and when the bone is very osteoporotic a nonsurgical approach seems advisable.

Biodegradable fixation of distal humeral physeal fractures.

Polyglycolic acid (PGA) has been used worldwide as a biodegradable suture material since 1970. Biodegradable polyglycolide implants were introduced in osteofixation of cancellous bone fractures in 1985. From September 1987 to September 1989, 19 consecutive children with physeal fractures of the distal humerus necessitating open reduction and internal fixation were treated by transphyseal biodegradable fixation using 1.5 x 60-mm2 self-reinforced polyglycolide (SR-PGA) pins. Included were nine displaced fractures of the lateral humeral condyle, five severe avulsions of the medial epicondyle of the humerus, four displaced fractures of the humeral capitellum, and one intraarticular fracture of the medial condyle of the humerus. After accurate reduction, two smooth Kirschner pins 1.5 mm in diameter were introduced across the growth plate for temporary fixation. The metallic pins then were removed one by one and subsequently replaced with the cylindrical SR-PGA pins 1.5 mm in diameter. After operation, a padded plaster splint was worn for four weeks. Neither secondary displacement nor signs of growth disturbance were seen during the 26-month follow-up time (mean, 17.2 months). Not only the reduction of the costs but also the psychological aspects should be considered when dealing with biodegradable fixation of physeal fractures in children. Transphyseal biodegradable fixation has established itself as a procedure of choice for handling simple physeal fractures.

Postoperative complications of distal humeral fractures. 27/96 adults followed up for 6 (2-10) years.

Of 96 adult patients with a distal intercondylar, intraarticular fracture of the humerus treated operatively during a 10-year period, 27 patients suffered a local complication, while the total number of individual complications were 34. There were six postoperative infections, 12 neural injuries, and 16 fixation failures. Because of the complication, a reoperation was performed in 12 of the 27 patients. The final outcome was assessed at a reexamination after a mean follow-up period of 6 (2-10) years. Three patients had a permanent dysfunction of the ulnar nerve. In another 3 patients, failure of the fixation had resulted in an established nonunion of the distal humerus. It appeared that the possibilities of internal fixation in several cases had been overestimated.

The knee in arthrogryposis multiplex congenita.

The functional, radiological, and ambulatory status of 30 patients (58 knees) with arthrogryposis multiplex congenita (AMC) were analyzed after a follow-up of 1-36 years. The muscular imbalance presented in many of these patients corresponded well to the type of deformity. The primary treatment was nonoperative in most cases. In spite of the initial promising results, a significant number of patients underwent operation for residual symptoms. Treatment of flexion contractures seems to be more discouraging than the treatment of extension contractures. On the other hand, the risk for degenerative arthritis seemed to be elevated, especially in the extension-contracture group.

[Cysts of the calcaneus, diagnosis and treatment]. / Kystes du calcanéum, diagnostic et traitement.

Cystic lesions of the calcaneus are almost always benign solitary bone cysts. They are in most cases asymptomatic; the need for surgery being diagnostic. The purpose with this study was to precisize the indications for surgical treatment of these lesions. We analyzed 11 cases of cystic lesions of the calcaneus. Two patients had atypical radiographs, four had symptoms and in 7 patients the lesion was found accidentally. Five patients underwent surgery. The histological findings in three cases with typical radiographs was solitary bone cyst and in the two cases with atypical radiographs respectively chondromyxoid fibroma and fibrous dysplasia. We made a solitary observation of raised intracystal pressure in one symptomatic patient with a solitary bone cyst. Asymptomatic cystic lesions of the calcaneus can safely be treated by simple observation if they fill the criterias for a typical solitary bone cyst of the calcaneus. Atypical cysts should be biopsied. Persisting pain is also an indication for surgery. Elevated intracystal pressure can contribute in the pathophysiological mechanisms producing pain.