Partial wound closure after surgical correction of equinovarus foot deformity.

Full correction of severe equinovarus foot deformities is frequently lost at the end of surgical release when the surgeon closes the skin incision. We retrospectively review 31 feet in 22 patients whose medial skin incisions were left open (typically 10 mm) to heal by secondary intention. The criterion to leave a wound open was if primary closure with the foot in full correction might compromise circulation to the skin or if closing the incision would require loss of corrected position. One or two cast changes were performed under outpatient anesthesia at 7- to 14-day intervals for wound care. All wounds except one were healed by week 6 at time of outpatient clinic cast removal. The appearance of the incisions is similar to feet in which primary closure is possible. One foot required split-thickness skin grafting at 3 weeks postoperatively to achieve wound coverage. There were no infections. We conclude that primary skin closure is not essential after surgical correction of equinovarus foot deformity, and that correction need not be compromised to approximate skin.

Chronologic outcome of surgical tendoachilles lengthening and natural history of gastroc-soleus contracture in cerebral palsy. A two-part study.

Medical records of 59 patients with cerebral palsy were reviewed retrospectively to evaluate results of tendoachilles lengthening. Surgical lengthening resulted in highly significant (p < 0.0001) initial average gains in dorsiflexion compared with baseline. These average improvements maintained their statistical significance for seven years postoperatively. The arc of motion was not significantly different postoperatively. The initial ambulatory level was improved in 55% of the patients and maintained in the remainder. However, 14 ankles (11.9%) in eight patients (13.6%) required repeat tendoachilles lengthening during the study period, primarily after gastrocnemius procedures. Calcaneus deformity occurred in 1.7% of the surgically treated ankles. To evaluate the potential for spontaneous improvement over time in fixed equinus deformity, the records of a group of 68 additional cerebral palsy patients were reviewed. Patients treated nonoperatively despite two examinations that demonstrated fixed lack of dorsiflexion, while not representing a true control group, showed no spontaneous improvement in equinus deformity through seven years postoperatively.

Diminished knee flexion after hamstring surgery in cerebral palsy patients: prevalence and severity.

A review of pre- and postoperative prone knee flexion (PKF) data after isolated hamstring tenotomy for 52 patients with cerebral palsy (CP) at an average follow-up of 3 years 4 months showed the frequency of diminished knee flexion to be 71%. Twenty-three percent of the knees actually had improved flexion, whereas 6% were unchanged. On the average, patients' flexion decreased 14.4 degrees from a preoperative PKF of 131.5 degrees to 117.1 degrees postoperatively (p < 0.0001). Only 11.5% of patients had PKF < 90 degrees at most recent follow-up, however; only 1.9% had PKF < 60 degrees. Thirteen percent of ambulators eventually required a rectus femoris transfer to correct "stiff-legged gait."

Observer variability in the radiographic measurement and classification of metatarsus adductus.

The classification system of Berg was evaluated using four observers and the radiographs of 42 feet from patients with metatarsus adductus. Interobserver disagreement in diagnosis was 36%. Intraobserver inconsistency averaged 26%. The error range for the lateral and anteroposterior talocalcaneal angle measurement was 13.6 and 15.1 degrees intraobserver and 19.8 and 25.2 degrees interobserver, respectively. There was no correlation between classification and the length of time required for cast correction. The irregularity of hindfoot ossification centers makes measurements inconsistent and seriously reduces the usefulness of classification based on such measurements.

Hamstring tenotomies in cerebral palsy: long-term retrospective analysis.

One hundred seventeen cerebral palsy patients were followed for a mean of 3.4 years after undergoing hamstring tenotomy by proximal semimembranosus release in conjunction with distal semitendinosus and biceps femoris release. Range of motion was significantly improved 1 year after the operation and remained so for 4 years. Thirty percent of nonambulatory patients improved at least one level in activity, some at up to 12 years of age. Minor recurvatum was observed at 1 year but became nearly nonexistent after 3-5 years.

Pseudomeningocele following spinal fracture. A case report and review of the literature.

Pseudomeningocele resulting from a fracture of the second thoracic vertebra occurred in a six-year-old girl. The condition was diagnosed using computed tomography (CT) and magnetic resonance imaging (MRI). MRI also showed a completely transected spinal cord. Unlike similar lesions reported previously, the pseudomeningocele was managed nonoperatively with observation alone and was seen to gradually resolve over several months. An overview of previously reported cases and indications for surgery is presented. The natural history appears to be spontaneous resolution. Surgery should be performed only for symptoms attributable to the lesion.

Longitudinal tibial epiphyseal bracket in Nievergelt syndrome.

A patient is described with lower extremity mesomelic dwarfism associated with bilateral congenital elbow, hip, and knee dislocations. Rhomboid-shaped tibiae and delayed ossification of the primary fibular ossification centers were demonstrated at birth. Plain films and magnetic resonance imaging revealed that the tibial deformities were due to the presence of longitudinal epiphyseal brackets. These brackets were observed at surgery and confirmed histologically. Recognition of the longitudinal epiphyseal bracket and its relationship to the tibial deformities seen in this patient with Nievergelt syndrome is important for planning surgical treatment.

Compression-distraction instrumentation of unstable thoracolumbar fractures: anatomic results obtained with each type of injury and method of instrumentation.

The quality of the reductions achieved in a consecutive series of 55 patients with unstable thoracolumbar fractures were correlated with the method of instrumentation, the type and level of injury, the effects of laminectomy and end-plate fractures, and the length of time from injury to surgery. It was found that many of these variables were associated with significant differences (less than 0.05) in the percent correction achieved in anterior compression, angle of deformity, and sagittal plane translation. Specifically: compression combined with distraction produced the best overall anatomic results, but bilateral compression and bilateral distraction were most effective for reducing flexion--distraction and flexion--axial compression (burst) fractures, respectively; two or more level laminectomies adversely affected reductions; end-plate fractures did not; the best reductions were obtained in flexion--distraction injuries; and the poorest reductions occurred in flexion--axial compression injuries, lumbar fractures, and fractures operated on 6 weeks or more after injury.

Relationship of spine deformity and pelvic obliquity on sitting pressure distributions and decubitus ulceration.

The distribution of pressure points in 16 patients with paraplegia, nine with ulcers, and six who were ulcer free were compared with the distribution in 15 normal individuals using an instrument capable of simultaneously measuring multiple pressure points under the buttocks and thighs. The nine patients with ischial and sacral decubiti showed redistribution of their sitting pressures posteriorly, asymmetrical loading of the ischiae, and higher than normal pressures under the sacrococcygeum. These abnormal pressures were associated with unbalanced scoliosis, pelvic obliquity, and the loss of physiological lordosis following a spinal fusion. We defined four criteria of risk for decubitus ulceration.

Physical work capacity in adolescent patients with mild idiopathic scoliosis.

The purpose of this study was to investigate the physical work capacity of adolescent patients with mild idiopathic scoliosis (less than 60 degrees). Fourteen subjects, who were being treated with a Milwaukee brace, were given a progressive exercise stress test. Ventilatory volume, frequency of breathing, end-tidal PCO2, heart rate, and blood pressure were continuously monitored and oxygen consumption (VO2) was computed for each work load. Results indicated that the majority of subjects were 1 to 4 standard deviations above the mean for nonhandicapped peers in expired ventilation, and all of the subjects were 2 standard deviations or more below the mean for their nonhandicapped peers in VO2max. The low work capacity was similar to that reported in individuals with much larger curves. Reduced work capacity was not apparently limited by maximal attainable ventilation or ventilatory pattern (frequency). Reduced aerobic fitness cannot be ruled out.

Congenital dislocation of the peroneal tendons in the calcaneovalgus foot.

Congenital dislocation of the peroneal tendons is a rare and infrequently reported deformity of the foot in the neonate. Four cases of this deformity associated with a congenital calcaneovalgus deformity of the foot have been treated and followed to the resolution of both of the deformities. The calcaneovalgus foot proved more resistant to correction and required more prolonged and aggressive treatment than was usual when it was found as an isolated deformity. All four patients demonstrated other stigmata of intra-uterine malposition and oligohydramnios or both. Our anatomical studies suggested that the superior peroneal retinacular ligament was the critical stabilising structure for the peroneal tendons. A concept of the pathogenesis of this deformity is discussed and a proven regimen for its treatment presented.

Long-term influence of calcitriol (1,25-dihydroxyvitamin D) and supplemental phosphate in X-linked hypophosphatemic rickets.

Ten patients with hypophosphatemic rickets (eight with X-linked familial form) were treated with vitamin D2 (10,000 to 75,000 units per day) and oral phosphate (1.5 to 3.6 gm) for a total of 438 treatment months. Therapy was then changed to calcitriol (17 to 34 ng/kg/day) and the same phosphate dose. Patients served as their own controls, and significant biochemical changes noted were an increase in immunoreactive parathyroid hormone from 29 +/- 9 (SD) microliters Eq/ml (pre-phosphate) to 62 +/- 34 on vitamin D2 plus PO4, then decreasing to 40 +/- 20 on a regimen of 1,25-dihydroxyvitamin D (1,25(OH)2D) plus PO4; serum PO4 rose from 2.44 +/- 0.45 (SD) mg/100 ml to 3.06 +/- 0.79 and then to 3.43 +/- 0.76; alkaline phosphatase activity decreased from 677 +/- 298 (SD) IU/liter to 457 +/- 183 to 290 +/- 176. Serum calcium and creatinine levels were unchanged. Both urinary calcium excretion and calcium-creatinine ratio decreased after therapy with 1,25(OH)2D. Urinary phosphate excretion was higher after calcitriol administration. Serum 1,25(OH)2D levels were low in these vitamin D2-treated patients, and an inverse relationship between serum 25(OH)D and 1,25(OH)2D was found. Improved bone mineralization was evident from serial assessment by photon absorptiometry, and radial bone mineral content rose from 75.3% +/- 2.2% of expected to 82.2% +/- 1.4% (P less than .005). Stature was improved when assessed by standard deviation for chronologic age but did not reach statistical significance. Long-term 1,25(OH)2D plus phosphate therapy appears to be more efficacious than vitamin D2 in this form of rickets, particularly in improving phosphate homeostasis.

A study of pressure distributions measured during balanced and unbalanced sitting.

An instrument that measures pressures distribution during normal and unbalanced sitting was developed and tested. Analysis of the distribution of pressure during sitting in fifteen normal patients showed that approximately 18 per cent of the body weight is distributed over each ischial tuberosity; 21 per cent, over each thigh; and 5 per cent, over the sacrum. Three patients who had problems with sitting balance showed foci of unequal pressure which are at risk for decubitus ulceration.

The midlumbar myelomeningocele hip: mechanism of dislocation and treatment.

We define the "bowstring" force of the iliopsoas, the force applied to the femoral head as the tendon angles across the hip joint, which we believe is an important cause of dislocation of the hip in patients with a midlumbar myelomeningocele. An operative procedure consisting of iliopsoas recession and suture of its tendon to the anterolateral hip joint capsule has been developed and used in 10 dislocated and 9 subluxated hips. The procedure was performed on patients with an average age of 6.6 months; the average follow-up was 45 months. Arthrography demonstrated the subluxation pattern of Leveuf in 17 hips. Surgical observations included: (a) flattening of the femoral head beneath the iliopsoas, (b) "bowstringing" of the iliopsoas across the hip joint, (c) posterolateral displacement of the femoral head with hip extension, (d) apparent increase in leg length after release of the iliopsoas, and (e) decrease of hip flexion contracture after iliopsoas release. Following iliopsoas recession alone, 11 hips were stable; 7 had subluxation; 1 was dislocatable. Secondary varus derotation osteotomy for valgus and anteversion was performed on five hips with subluxation; each was stable at review. A combined varus derotation osteotomy and Chiari osteotomy was performed on the one dislocatable hip that remained dislocatable. Therefore, at review 16 of 19 hips were stable, two have subluxation, and one was dislocatable. Early surgical treatment to prevent secondary adaptive changes in the hip is recommended. Additional surgery to correct retained valgus and anteversion is frequently necessary to achieve stability.

Congenital generalized fibromatosis. Case report and literature review.

A typical case of congenital generalized fibromatosis (CGF) is presented and the literature on this entity is reviewed. CGF is a rare condition which is probably heritable. It is manifested in infancy. Because of the unusual biological behavior of the fibromata, two clinical courses occur--death, if vital viscera are involved, or regression of the lesions and survival without significant disability. Including the present example, 63 cases have been reported.