Equinus and cerebral palsy--its management.

Orthopaedic procedures for the correction of equinus deformity are effective in the treatment of spastic cerebral palsy. The best operative procedure for the correction of fixed equinus deformity in our series was the sliding lengthening of the heel cord. Adequate postoperative management of these patients is essential in order to obtain a good result. Long-term support at night during the growing period is necessary to prevent recurrent equinus. An exercise regimen to develop balanced muscle function is essential for a satisfactory result.

Recurrent subluxation and dislocation of the patella in association with athletic injuries.

Seventy-one patients with 81 operations for correction of patellar instability are reviewed. Follow-up was for at least five years. The various preoperative symptoms, signs, and radiographic findings are presented. Two types of patellar instability become clear. One type is usually bilateral and secondary to general ligamentous laxity. A second type, usually unilateral with distinct physical findings, is secondary to trauma. The operative technique and results of surgery and physical therapy are discussed. A new rational approach to the operative treatment of recurrent subluxation and dislocation of the patella is proposed. The operative procedure would depend on the Q angle. For a Q angle of less than 14 degrees, a proximal realignment is sufficient. For a Q angle greater than 14 degrees, a distal realignment would be necessary in addition.

Adjuvant treatment of osteogenic sarcoma with high-dose cyclophosphamide.

Six patients with osteosarcoma and no evidence of metastases received postoperative adjuvant chemotherapy with high-dose cyclophosphamide (25 mg/kg iv every other day for five doses). Three of these patients are alive without evidence of disease at 2 1/2, 3, and 5 years following diagnosis. The regimen was tolerable in terms of toxicity. Cyclophosphamide in high doses may be effective adjuvant therapy in some patients with osteosarcoma.

Combined therapy of osteosarcoma: preoperative irradiation, surgery, and chemotherapy.

The rationale for prebiopsy and preoperative irradiation in a multimodal approach to treatment of osteosarcoma is presented. Six patients with osteosarcoma underwent preoperative irradiation, amputation, and elective chemotherapy. Five of these also received prebiopsy irradiation: three survive without metastases at 29, 36, and 56 months, with no therapy for 10, 16, and 37 months, respectively; two patients died at 6 and 19 months of pulmonary metastases which appeared at 2 and 10 months, respectively. The latter two did not receive prebiopsy irradiation. Another patient, whose pulmonary metastasis regressed at 6 months with adriamycin and was later resected, died of cardiac failure at 59 months without evident metastasis. Immunologic aspects of the disease are also discussed.

The management of spastic deformities of the foot and ankle.

The most common ankle and foot deformities in cerebral palsy are equinus, equinovalgus, equinovarus, calcaneus and hallux valgus. It makes little difference how the length of the triceps surae is re-established and how its stretch reflex is weakened as long as the patient is carefully chosen, the procedure done well and the postoperative regimen prolonged and detailed. The most common cause of failure is inadequate use of night support during growth to prevent recurrence. Significant equinovalgus has been successfully managed by heel cord lengthening and subtalar arthrodesis. The arthrodesis should not be performed unless the equinus has been corrected prior to or at the same time as the procedure to correct the valgus. Overcorrection must be avoided. Where equinovarus needs surgical correction and no bone deformity exists, heel cord and posterior tibial lengthening are successful. If there is significant bone deformity, a triple arthrodesis may also be necessary when growth is complete. The latter procedure should not be used to correct equinus for it ends up with a foot short in height, length and width.

Extremity gunshot wound and gunshot fracture in civilian practice.

The civilian gunshot wound is a low velocity injury. Temporary cavitation does not occur in the low velocity wound and damage is confined to the projectile pathway. Extensive debridement is not indicated for this injury. Surgical cleansing is used to convert the open, contaminated wound to a clean, closed wound. Reparative and definitive reconstruction then follow to restore form and function with minimized patient hazard.