Rectus-sparing approach to the periacetabular osteotomy in adolescents preserves hip flexion strength.

PURPOSE: The classic periacetabular osteotomy (PAO) approach can result in hip flexor weakness in adolescents. The rectus-sparing approach (PAO-RS) preserves the origin of the rectus femoris tendon which may prevent hip flexor weakness and improve functional outcome. METHODS: This is a prospective analysis of adolescents treated with a PAO or PAO-RS. The PAO group included 24 hips/21 patients (18 female, meanage 16 years (sd 4)); the PAO-RS group included ten hips (eight female, mean age 16 years (sd 1)). Preoperatively, the PAO group had decreased hip flexion strength compared with the PAO-RS group (83 Nm/kg versus 102 Nm/kg). A subset of PAO patients (n = 13 hips/12 patients, nine female, mean age 15 years (sd 3)) were matched for preoperative flexion strength to the PAO-RS group. Radiographic parameters, modified Harris hip score (mHHS), isokinetic hip strength and instrumented motion analysis preoperatively, six months and one-year postoperatively were compared. RESULTS: There were no differences in preoperative deformity, postoperative correction or degree of correction between groups. Hip flexor strength decreased significantly at six months in the PAO group compared with the PAO-RS group (-35 Nm/kg versus -7 Nm/kg; p = 0.012), as did hip flexion pull-off power (1.33 W/kg PAO versus 1.76 W/kg PAO-RS; p = 0.010). Hip flexion strength improved from six months to one year in the PAO group, with no significant differences in strength at one year between groups (80 Nm/kg versus 90 Nm/kg). There were no differences between groups in mHHS any time point; both groups improved significantly postoperatively. CONCLUSION: Preserving the rectus femoris may lead to improved short-term hip flexor strength and pull-off power. Further assessment at long-term follow-up is needed to determine if this strength leads to improved functional outcomes. LEVEL OF EVIDENCE: II.

Functional Outcomes Following Operative Treatment of Tibial Tubercle Fractures.

BACKGROUND: Quantitative evaluation of the functional results of surgically managed tibial tubercle fractures in adolescents is unreported in the orthopaedic literature. METHODS: All patients treated surgically for unilateral tibial tubercle fractures at a single institution from 2007 to 2011 were invited to return for functional evaluation. Fractures were classified using the Ogden classification system. Clinical examination at follow-up included passive knee range of motion and thigh circumference. Side-to-side knee extension strength deficits were evaluated using a Biodex dynamometer. Patient-reported outcomes were assessed using the Pediatric-International Knee Documentation Committee Subjective Knee Form (Pedi-IKDC), Tegner-Lysholm Knee Scoring Scale, and Visual Analog Pain Scale. Chart review was performed to determine postoperative protocols including the use of physical therapy and protected weight bearing. Functional parameters were compared between the involved and uninvolved extremities using the Wilcoxon Signed Ranks Test and the Spearman correlations were performed to identify any relationships between perioperative factors, functional parameters, and subjective outcomes. RESULTS: In total, 19 of 42 patients completed clinical and functional testing and 18 of 19 completed all outcome surveys. Average age at injury was 13.9 years and average follow-up was 3.0 years. There was no statistical difference in knee range of motion between sides, however, thigh circumference was slightly smaller in the injured extremity (median difference, 1.7 cm at 15 cm above the patella and 4.0 cm at 50% of the length of the thigh). In total 5/19 subjects (26%) had a significant quadriceps extension strength deficit on the involved leg compared with the contralateral side. The median Visual Analog Pain Scale for affected limbs was 8/100 and for unaffected limbs was 6/100 (P=0.017). The Tegner-Lysholm Scale revealed 9 excellent results, 5 good, 4 fair, and 1 poor (median, 90/100). Results of the Pedi-IKDC were 11 excellent, 3 good, 2 fair, and 3 poor results (median, 91/100). Outcome scores did not correlate to diminished strength or thigh circumference. No difference in outcome based upon body mass index, postoperative weight-bearing status, Ogden classification, or postoperative physical therapy was noted using regression analysis. CONCLUSIONS: Despite promising objective results, clinical outcomes measured by subjective validated surveys are not all excellent. LEVEL OF EVIDENCE: Level III.

Effects of comprehensive osteopathic manipulative treatment on balance in elderly patients: a pilot study.

CONTEXT: Falls, many of which are caused by balance problems, are a leading cause of injuries in elderly persons. Few studies have investigated osteopathic manipulative treatment (OMT) for patients with balance problems. OBJECTIVE: To test whether an OMT protocol with an emphasis on cranial manipulation can improve vestibular balance control structures and postural stability in a healthy elderly population. DESIGN: A pilot prospective clinical trial. SETTING: Research laboratories of the University of North Texas Health Science Center Texas College of Osteopathic Medicine in Fort Worth. PATIENTS: Forty healthy elderly patients aged 65 or older were enrolled and separated into an OMT group and a control group. Owing to the recruitment process and limited time for the study, the first 20 patients to enroll were in the OMT group, and the next 20 were in the control group. Patients were excluded if they had a condition that could impair balance. INTERVENTION: The OMT protocol comprised 7 OMT techniques applied weekly by the same osteopathic physician before balance tests. Patients in the control group received no treatment. MAIN OUTCOME MEASURES: Patients were asked to stand on a force plate and to perform 3 balance tests: (1) eyes open, (2) eyes closed, and (3) a modified Romberg test. The center of pressure between their feet was recorded for 30 seconds. The average center of pressure displacement for each test was used to determine anteroposterior (AP) sway and mediolateral (ML) sway. Balance tests were performed each week for 4 weeks. Tests were performed at the same time of day as the first test. RESULTS: Changes in AP sway values between visits 1 and 4 were as follows: eyes open, -0.72 and 0.75 mm for the control and OMT groups, respectively; eyes closed, -0.49 and 0.44 mm; and Romberg test, -0.17 and 0.52 mm. The changes in ML sway values between visits 1 and 4 were as follows: eyes open, -0.58 and 0.07 mm for the control and OMT groups, respectively; eyes closed, -0.21 and 0.03 mm; and Romberg test, -0.15 and 0.39 mm. The OMT group had significantly reduced sway for the eyes-open test after 4 visits (P=.001). CONCLUSION: The OMT protocol used in the present study improved the postural stability of healthy elderly patients, as measured by changes in sway values. (ClinicalTrials.gov number NCT01153412).