Idiopathic toe-walking: does treatment alter the natural history?

Outcomes from observation or cast or surgical treatment of idiopathic toe-walking were determined in 136 children. With patient-determined outcomes, for the observation group, gait was normal in 6%, improved in 45%, and unchanged in 49%. Physician-determined outcomes demonstrated normal gait in 12% of children. Outcomes were similar in the cast group. With patient-determined outcomes in the surgical group, 22% walked normally, 50% had improved, 26% were unchanged, and 2% had deteriorated; with physician-determined outcomes, 37% walked normally. The natural history, determined from the observation group, was for idiopathic toe-walking to persist, albeit with improvement in 50%. Cast treatment did not alter the natural history. Surgical treatment may influence the outcome, but indications for surgery need to be clarified.

Age-related walking in children with spina bifida.

The aim of this study was to examine children with myelomeningocele (spina bifida) who were investigated according to the level of neurosegmental lesion and to determine the number who walked and their average age at commencement/cessation of walking. The data have been collected since 1978 at the Royal Children's Hospital, Melbourne during annual evaluations of patients with spina bifida and high-level paralysis. After screening for established criteria and assigning to a neurosegmental lesion level, 173 children were examined for their ability to walk, with or without aids, in a community setting. Thirty-five children had lesions at the thoracic level, and seven walked at a mean age of 4 years 6 months. Three children with a lesion at the thoracic level ceased walking at a mean age of 7 years 6 months. Ten children had lesions at the high-lumbar level (L1/2), and five walked at a mean age of 5 years 2 months. Three children who had lesions at the high-lumbar level ceased walking at a mean age of 6 years 11 months. Fifteen children had lesions at the mid-lumbar level (L3) and nine walked at a mean age of 5 years. Three ceased walking at a mean age of 7 years. Forty-five children had lesions at the low-lumbar level (L4/5) and 38 walked at a mean age of 3 years 10 months. Five ceased walking at a mean age of 9 years 1 month. Sixty-eight children had lesions at the sacral level; all of whom walked at an average age of 2 years 2 months. None had ceased walking by the end of the study period. Delay in achieving ambulation can be expected in all children with spina bifida, including those with low neurosegmental level lesions. Furthermore, some children with high lesion level, given the opportunity, might be expected to ambulate effectively in the community but may cease walking after 3 to 4 years of this activity, which is earlier than previously recorded.

Bilateral dislocation of the hip in spina bifida: a long-term follow-up study.

Nineteen patients with spina bifida and bilateral dislocation of the hips were studied with a minimal follow-up of 10 years. The average age at review was 21 years (range, 10-31). Ten patients had an upper neurologic level (thoracic to L3), and nine had a low lesion (L4 to sacrum). Three patients had no hip surgery. A closed or open reduction was performed in 12 hips, supplemented by one or more surgical procedures. Of these, 10 remained enlocated, and two had redislocated. In all other hips, several surgical procedures were performed, aimed at improvement of hip-flexion deformity or stability. At follow-up, one patient had occasional pain in one hip, which was dysplastic. Of the 10 patients with a high lesion, only two were walkers, but both had bilateral dislocation of the hips at follow-up. In contrast, all nine patients were walkers, but four of these had bilateral dislocation at follow-up. We found that a level pelvis and good range of motion of the hips are more important for ambulation than is reduction of bilateral hip dislocation.

Incidence and type of hindfoot deformities in patients with low-level spina bifida.

In a consecutive series of 174 children with low-level spina bifida, there was hindfoot deformity in 263 of the 348 feet; 86 were in equinus, 108 were in calcaneus, 41 were in valgus, 20 were in varus, and eight had convex pes valgus. Surgery was performed on 222 (64%) feet. The deformities were symmetric in 114 children. Spasticity causing deformity necessitated surgery in only 44 feet. Calcaneus deformity in the foot is considerably more common in patients with L4 lesions, and in these circumstances, muscle imbalance is clearly a major factor. However, many patients with calcaneus deformity had L5 or sacral lesions. This suggests that muscle imbalance is not so important a factor as has been thought in the causation of deformity in the lower limb in myelomeningocele.

Ollier's disease: varus angulation at the lower femur and its management.

Attention is drawn to the high incidence of varus angulation in the lower femur in Ollier's disease; eight of a total of 14 patients with this condition have this deformity. There may be retardation or arrest of the medial portion of the lower femoral growth plate. One case demonstrates a bone bridge, a condition not previously described in Ollier's disease. The limb-length inequality and varus angulation require concurrent management by a variety of techniques, which are described. Three of the eight patients have reached skeletal maturity; the remainder provide useful information on the condition and are a stimulus for discussion of future management.

Benign anterior knee cyst in early childhood.

BACKGROUND: Anterolateral knee cysts are not uncommon in the first 7 years of life, but have not been described in the literature. METHODS: Four patients presenting with an asymptomatic lump on the anterolateral joint line were reviewed. RESULTS: The lump remains asymptomatic. CONCLUSIONS: Anterolateral knee cysts of childhood are benign and do not require treatment. Their cause is conjectural.

Plantar fibromatosis of the heel in children: a report of 14 cases.

Based on a study of 14 patients younger than 16 years, we found that lumps on the plantar aspect of the anteromedial portion of the heel pad can safely be observed. Many remained small and asymptomatic, some disappeared, and two that required repeated excision biopsy did not subsequently recur. The six patients who were subjected to excision biopsy were found to have plantar fibromatosis. This very precise heel site is a characteristic situation for plantar fibromatosis in childhood.

Surgical release of knee flexion contractures in myelomeningocele.

We report the results of a prospective study of the surgical release of 45 knee flexion contractures in 28 patients with myelomeningocele. The neurosegmental level was thoracic in ten patients, L1/2 in one, L3/4 in 11, and L5/S1 in six. In walkers the indication for surgery was a fixed flexion contracture impeding walking, and in non-walking patients it was a flexion contracture impeding transfers or sitting balance, or likely to do so with increasing deformity. The mean age at surgery was 6.4 years (3 to 21) and the mean period of follow-up 13 years (4 to 20). The mean knee flexion contracture before surgery was 39 (25 to 70) which improved to 5 degrees at maximum correction and to 13 degrees at latest follow-up. We conclude that surgical release of knee flexion contractures in myelomeningocele improves gait in all children who walk, particularly those with low lumbar lesions. Recurrence of knee flexion contractures after surgical release is most common in those with thoracic lesions who do not achieve independent walking.