Clinical utility of the Duncan-Ely test for rectus femoris dysfunction during the swing phase of gait.

The Ely Test (or Duncan-Ely test) has been accepted as a clinical tool to assess rectus femoris spasticity by passively flexing the knee rapidly while the patient lies prone in a relaxed state. In this retrospective review, patients' dynamic knee range of motion (ROM) during gait and an electromyogram (EMG) were compared with the results of the Ely test. Data for 70 patients (44 males, 26 females; 104 limbs) were included. Mean age of patients was 13 years, SD 9 years, range 4 years 5 months to 54 years. All patients were diagnosed with cerebral palsy (spastic diplegia, n = 42; spastic quadriplegia, n = 15, and hemiplegia, n = 13). All patients were ambulatory (50 independent, 20 with assistive devices). A standard matrix was used to calculate sensitivity and specificity of the Ely test as well as its positive and negative predictive value. For the gait variables examined (decreased dynamic knee ROM, timing of peak knee flexion, and abnormal EMG in swing) the sensitivity of the Ely test ranged from 56 to 59% and the specificity ranged from 64 to 85%. For the same variables the positive predictive value ranged from 91 to 98% and the negative predictive value ranged from 4 to 19%. The Ely test was shown to have a good positive predictive value (i.e. the certainty about the presence of rectus spasticity in patients with a positive Ely test result) for rectus femoris dysfunction during gait.

Supracondylar fractures of the humerus associated with ipsilateral forearm fractures in children: a report of forty-seven cases.

Supracondylar fractures of the humerus associated with ipsilateral forearm fractures are uncommon and treatment recommendations are controversial. The purpose of this study was to determine whether pin fixation of both fracture components, humerus and forearm, would improve the outcome. In a two-center trial, 884 children sustaining supracondylar fractures of the humerus were retrospectively reviewed, and 47 (5.3%) showed associated ipsilateral forearm fractures. Of those, 29 underwent Kirschner-wire fixation of the forearm fracture, and 18 of the forearm fractures were treated with casting alone. Three of the 18 forearm fractures with casting alone reangulated. There were no reangulations in the patients who had pin fixation of their fractures. There were no complications due to pin fixation in the humerus or the forearm. In unstable supracondylar humerus and forearm fractures, stabilization with pin fixation to prevent reangulation should be considered.

Treatment of functional limitations at the knee in ambulatory children with cerebral palsy.

The gait of ambulatory children with cerebral palsy frequently involves abnormal knee motion. Spasticity, muscle contracture formation, impairments of motor control, weakness, balance deficits, and extrapyramidal motions can all contribute to the functional limitations imposed at the knee. Careful clinical evaluation of the child and their gait must be performed in order to determine the best individual course of treatment. Often, three-dimensional motion analysis with assessment of muscle activity and force is necessary to completely assess the complexities of gait. Several typical gait patterns have been described involving the knee, including 'jump knee', 'crouch', 'true equinus', 'apparent equinus', 'recurvatum' and 'stiff knee' gait. Each of these gait patterns is defined here and discussed using case examples. These typical gait patterns are usually accompanied by involvement at the hip and ankle and may be combined with transverse plane rotational abnormalities. Treatment options such as rehabilitation (physiotherapy, casting, strengthening, and/or orthoses), spasticity management (intramuscular injections of phenol, alcohol, and botulinum toxin type A) and orthopaedic approaches are discussed for each entity.

Congenital coxa vara: computed tomographic analysis of femoral retroversion and the triangular metaphyseal fragment.

Three patients with congenital coxa vara studied with two- and three-dimensional computed tomographic (2DCT and 3DCT) methods are reported. In all cases, the femoral retroversion was documented and subsequently corrected by proximal femoral osteotomy. In two patients with isolated coxa vara, the physeal-femoral neck angle was decreased as seen in slipped capital femoral epiphysis in adolescents. Our studies suggest that the triangular metaphyseal fragment reflects a Salter-Harris type II separation pattern through the defective femoral neck. The epiphysis and attached triangular fragment slip from the normal superoanterior portion of the neck in an inferior-posterior direction. The treating surgeon should be aware of the often marked femoral retroversion component present in severe congenital coxa vara. This knowledge allows surgical planning for corrective osteotomies that will better normalize hip mechanics. A combination of marked valgus and flexion with internal rotation of the distal fragment are required to fully correct the deformity.

The effect of valproic acid on blood loss in patients with cerebral palsy.

Valproic acid (VPA) is used in the treatment of seizure disorders often present in patients with cerebral palsy. The charts of 114 patients with cerebral palsy were reviewed to evaluate the effect of VPA on blood loss during spine surgery. Forty-one patients had seizure disorders. Of these, 18 were taking VPA as monotherapy (group III) and the remaining 23 patients were taking other antiseizure medications, including two taking VPA (group II). There was a significant increase in the number of patients with abnormal bleeding times and a significant difference (p < 0.001) in blood loss (ml/kg) in patients taking VPA as monotherapy (38.6 ml/kg vs. 30.0 ml/kg). There was also increased blood-product administration postoperatively in the VPA monotherapy patients. Physicians should be aware of this potential association between VPA use and increased blood loss. The routine laboratory tests of complete blood count, prothrombin time, and partial thromboplastin time will not adequately screen for the platelet-mediated effects of VPA.

Double-blind study of botulinum A toxin injections into the gastrocnemius muscle in patients with cerebral palsy.

The purpose of this study was to quantify the gait of subjects receiving two injections of either botulinum A toxin or saline vehicle into the gastrocnemius muscle(s). The study group consisted of cerebral palsy patients who walked with an equinus gait pattern. This study was a randomized, double-blinded, parallel clinical trial of 20 subjects. All were studied by gait analysis before and after the injections. There were no adverse effects. Peak ankle dorsiflexion in stance and swing significantly improved in subjects who received the drug and not in controls. Results of this double blind study give support to the short term efficacy of botulinum toxin A to improve gait in selected patients with cerebral palsy.

Femoral anteversion and neck-shaft angle in children with cerebral palsy.

A database of femoral anteversion and neck-shaft angle was compiled of measurements made by the trigonometric fluoroscopic method of 147 patients (267 hips) with cerebral palsy. The angles of femoral anteversion were similar at early ages between healthy children and children with cerebral palsy. However, as the age of the children increased, those with cerebral palsy showed little change in anteversion angle, whereas the healthy children had progressively decreasing angles of femoral anteversion as they approached adulthood. The neck-shaft angle was increased significantly in children with cerebral palsy compared with the angles of healthy children. Patients who were ambulatory were shown to have an increased angle of femoral anteversion and a decreased neck-shaft angle compared with nonambulatory patients. There was no significant difference in angles among the various distributions of involvement, including patients with diplegia, hemiplegia, and quadriplegia.

Intramedullary Kirschner wire fixation of open or unstable forearm fractures in children.

This retrospective review evaluates the efficacy of standard intramedullary Kirschner wires (K-wires) for the treatment of open or unstable diaphyseal forearm fractures in 32 children with a mean follow-up of 13 months. Thirty-one patients had an excellent result, and one patient had a good result. Average time to bridging cortex was 3 months. Four patients lacked full pronation and supination, with none lacking >20 degrees, and no patients had evidence of growth-plate arrest. Nine complications occurred in eight patients: lost reduction after K-wire removal (three), refracture (two), deep infection (one), pin-site infection (one), transient anterior interosseous nerve palsy (one), and skin ulcer over buried K-wire (one). Both infections occurred in cases in which the K-wire ends were left outside the skin. Each case of lost reduction occurred in single-bone fixation cases when the K-wires were removed before 4 weeks. In children, intramedullary fixation by using standard K-wires plus cast immobilization provides effective treatment for the problematic open or unstable diaphyseal forearm fracture when closed management has failed. Refinement of the technique may help to avoid complications. We now recommend burying the K-wires under the skin for 3-5 months and stabilizing both the radius and ulna with an intramedullary K-wire.

Heel pain in children. Diagnosis and treatment.

Heel pain in children is common, and its evaluation is challenging. Medical history and physical examination may be unrevealing owing to children's limited communication skills. Often, advanced laboratory and imaging studies are required to make an accurate diagnosis. The most common causes of heel pain in children are apophysitis, enthesopathy, and overuse syndromes such as tendinitis. Juvenile rheumatoid arthritis is relatively uncommon. In very active children, occult fractures must also be evaluated. Pain unrelated to activity may indicate tumors, infection, or congenital problems. In general, heel pain in children is treated nonoperatively. For fractures in particular, children are less likely than adults to receive surgical treatment.

Kinematic and kinetic analysis of distal derotational osteotomy of the leg in children with cerebral palsy.

Patients with cerebral palsy often develop rotational deformities of the lower extremities. These deformities may be caused by abnormal muscle tone, soft-tissue contractures, or bony malalignment. When rotational deformity persists after correction of the soft-tissue components, bony-realignment procedures are warranted to improve gait in ambulatory patients. We performed a retrospective review of 10 ambulatory children with cerebral palsy and tibial torsion who underwent 13 distal tibial and fibular derotation osteotomies. Preoperative and postoperative three-dimensional gait analysis were used to determine the effect of distal tibial and fibular derotation osteotomy on tibial rotation, foot-progression angle, gait velocity, and moments about the ankle. Mean tibial rotation and foot-progression angle were significantly improved by the procedure. Gait velocity improved but not significantly. Moment data demonstrated a trend toward normal. This study demonstrates that the derotational distal tibial and fibular osteotomy stabilized with percutaneous crossed Kirschner wires is a safe, reliable, and effective procedure for correcting rotational deformities of the leg in patients with cerebral palsy.

The surgical treatment of spasticity.

The surgical treatment of spasticity has been aimed at four different levels: the brain, the spinal cord, peripheral nerves, and the muscle. Stereotactic neurosurgery, whether involving the globus pallidum, ventrothalamic nuclei, or the cerebellum, has had little success. Cerebellar pacemakers have been tried: results have been mixed but not ultimately encouraging. Selective posterior rhizotomy is currently the most widely used and effective central nervous system procedure. Posterior rootlets in L2-S2 are exposed and tested with electrical stimulation. Those showing abnormal response are transected. Contraindications include weakness and marked fixed contracture. Neurectomy has been tried for spasticity, but the results have not been encouraging and the adverse effects may be severe. Musculoskeletal surgery remains an important procedure for treatment of contractures secondary to spasticity.

Psoas release at the pelvic brim in ambulatory patients with cerebral palsy: operative technique and functional outcome.

Seventeen patients with cerebral palsy (29 hips) underwent psoas recession at the pelvic brim. The operative technique was a direct anterior approach, lateral to the femoral sheath. There were no infections or nerve or arterial injuries. After surgery, clinical examination revealed that fixed hip-flexion contractures decreased significantly in all patients. All of the subjects retained the ability to flex the hip against gravity and against manual resistance. All of the subjects underwent pre- and postoperative gait analysis. Stance-phase dynamic minimum hip flexion decreased significantly. Dynamic pelvic tilt improved to a statistically significant level for the younger children but did not for the group as a whole. There was less improvement with increasing age. Step length was significantly increased and cadence significantly decreased in all patients. We conclude that psoas recession at the pelvic brim, by using the anterior approach, lateral to the femoral sheath, is a safe, reliable, and effective procedure for children with cerebral palsy who have excessive anterior pelvic tilt and excessive dynamic hip flexion or hip-flexion contracture.

Complications of iliac crest bone graft harvesting.

Autologous bone grafts harvested from the iliac crest are commonly used in reconstructive orthopaedic surgery. Autologous bone is used to help promote bone healing in fractures and to provide structural support for reconstructive surgery. The results of autologous bone grafting are more predictable than the use of xenografts, cadaveric allografts, or synthetic bone substitutes because autologous bone grafts provide osteoinductive and osteoconductive properties, are not immunogenic, and are usually well incorporated into the graft site. In a retrospective review of 414 consecutive cases of iliac crest bone graft procedures performed at Brooke Army Medical Center from 1983 to 1993, 41 (10%) minor and 24 (5.8%) major complications were identified. Minor complications included superficial infections, superficial seromas, and minor hematomas. Major complications included herniation of abdominal contents through massive bone graft donor sites, vascular injuries, deep infections at the donor site, neurologic injuries, deep hematoma formation requiring surgical intervention, and iliac wing fractures. Harvesting of iliac crest bone graft can be associated with significant morbidity. However, with adequate preoperative planning and proper surgical technique, the incidence of these complications can be reduced.

The effect of postoperative wound drainage reinfusion in reducing the need for blood transfusions in elective total joint arthroplasty: a prospective, randomized study.

A prospective, randomized study was conducted in 24 patients using the Solcotrans Orthopaedic Drainage Reinfusion System (Smith & Nephew Richards Inc, Memphis, Tenn) for postoperative blood salvage in total joint arthroplasty. The amount of postoperative autologous blood salvage averaged 946 mL. Only 25% of the study group required postoperative transfusions, compared to 83% of the control group (P = .016). In total knee arthroplasties, only 11% of the study group required transfusions, compared to 78% of the control group (P = .018). There were no transfusion reactions, infectious complications, or coagulopathies. Postoperative blood salvage is a safe, reliable, and effective source of autologous blood.

Percutaneous muscle biopsy in the diagnosis of neuromuscular disease.

Open biopsy of affected muscle is traditionally used to obtain tissue samples for histologic, histochemical, and biochemical analysis in patients with suspected myopathies. Percutaneous muscle biopsy offers certain advantages over the open technique: it can be performed in an outpatient clinic or as day surgery, usually with a local anesthetic for children greater than 12 years of age, and thus is less costly, more efficient, and less risky. There is also a significant difference in the residual scar. We reviewed the charts of 379 children and adults who had undergone percutaneous muscle biopsy to determine the usefulness of this alternative technique. The analysis could be accurately performed even though the muscle tissue was not at resting length and not oriented in any particular manner, and in nearly all patients sufficient tissue could be obtained for analysis without open biopsy.

Colonic pseudoobstruction associated with patient-controlled analgesia after total joint arthroplasty.

Patient-controlled analgesia (PCA) is a concept that permits patients to administer a prescribed dose of narcotic to themselves when they experience pain. Six patients developed colonic pseudoobstruction after the use of morphine sulfate administered via a PCA infuser. Early recognition and prompt treatment make this a transient, reversible illness. Treatment includes discontinuing the use of the PCA morphine, eliminating oral intake, ensuring adequate hydration and electrolyte balance, placing a nasogastric tube, rolling the patient, and closely observing for signs and symptoms of worsening colonic distention and possible rupture.