Evaluation of the functional outcome of a percutaneous technique in correction of excessive anteversion in cerebral palsy.

In cerebral palsy, patients' excessive femoral anteversion is one of the most common skeletal abnormalities. The general agreement is concurrent correction of both soft tissue and bony deformities during the same operative setting by combining open femoral derotation osteotomy (FDO) with soft tissue releases. Fifty-one children (75 lower limbs) with cerebral palsy with a mean age of 10.7 years (range 6-16 years) fulfilling the inclusion criteria who underwent percutaneous FDO and when needed customized soft tissue releases. Derotation was maintained by a pin-in-cast technique. The mean follow-up was 24 m (range 14-36 m) and gross motor function classification system, functional mobility scale (FMS) and anteversion angle using the Staheli rotational profile were evaluated. Femoral anteversion was accurately measured by hip ultrasonography followed by a preoperative three-dimensional gait analysis. Preoperative and postoperative data were statistically analyzed to reveal the validity of this method. Internal and external hip rotation improved significantly (P < 0.001, respectively). Mean cast and Schanz screw application time was 49 days and all patients achieved independent walking for at least 5 m within 7 weeks. FMS, ultrasonography measured hip anteversion and gait kinematics also improved significantly (P < 0.01, respectively). Two patients (3.92%) developed a mild knee flexion contracture which resolved completely with physiotherapy at 12 m. The pins-in-fiberglass cast provides sufficient rigid fixation to constitute a reliable and reproducible method permitting early weight bearing. It is versatile enough to allow concomitant soft tissue procedures and correction of other accompanying bony deformities.

Double column osteotomy for correction of residual adduction deformity in idiopathic clubfoot.

INTRODUCTION: Adduction of the forefoot is the most common residual deformity in idiopathic clubfoot. The 'bean-shaped foot', which is a term used to describe a clinical deformity of forefoot adduction and midfoot supination, is not uncommonly seen in resistant clubfoot. SUBJECTS AND METHODS: Fifteen children (20 feet) with residual forefoot adduction in idiopathic clubfeet aged 3-7 years were analyzed clinically and radiographically. All of the cases were treated by double column osteotomy (closing wedge cuboid osteotomy and opening wedge medial cuneiform osteotomy) with soft tissue releases (plantar fasciotomy and abductor hallucis release), to correct adduction, supination and cavus deformities. Pre-operative measurements of certain foot angles were compared with their corresponding postoperative values. RESULTS: A grading system for evaluation of the results using a point scoring system was suggested to evaluate accurately both clinical and radiographic results after a follow-up period of an average of 2.3 years. Eight feet (40%) had excellent, eight (40%) good, three (15%) fair, and one (5%) poor outcome. There was no major complication. There was significant improvement in the result (P > 0.04). CONCLUSIONS: Double column osteotomy can be considered superior to other types of bone surgeries in correction of residual adduction, cavus and rotational deformities in idiopathic clubfoot.

Repair of chronic rupture of the achilles tendon using 2 intratendinous flaps from the proximal gastrocnemius-soleus complex.

BACKGROUND: Chronic rupture of the Achilles tendon is a surgical challenge, owing to the presence of a gap between the retracted ends, which renders direct repair almost impossible. PURPOSE: In this study, 2 intratendinous distally based flaps fashioned from the proximal gastrocnemiussoleus complex are used to bridge the gap between the retracted edges of the ruptured Achilles tendon. The flaps are placed in the same line of pull of the ruptured tendon, in an effort to make the graft mimic the original biomechanics as much as possible. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Eleven patients (9 male and 2 female) with neglected ruptures of the Achilles tendon with retracted ends were included in this study. Two flaps fashioned from the proximal gastrocnemiussoleus complex were rotated over themselves, passed through the proximal stump, and then securely inserted into a previously prepared bed in the distal stump. RESULTS: The patients were followed up for a period of 6 to 9 years. At the final follow-up, all patients were able to return to their preinjury level of activity within a period of 6 to 9 months. The mean preoperative American Orthopedic Foot and Ankle Society score was 42.27, whereas it was 98.91 at the final follow-up, with a range of 88 (in 1 patient) to 100 points (in 10 patients). All 11 patients showed statistically significant improvement according to the Holz rating system. CONCLUSION: This technique allows for a bridging of the defect present in chronic ruptures of Achilles tendons, with a minimum of complications and a good final outcome.

Open reduction and posterior capsular shift for cases of neglected unreduced posterior shoulder dislocation.

BACKGROUND: Neglected unreduced posterior shoulder dislocation is a challenging orthopaedic problem. PURPOSE: To evaluate the results of open reduction with posterior cruciate capsular repair for such cases. This corrects the wide posterior capsule, which is the main pathologic entity. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Over a period of 5 years, 17 patients with unreduced neglected posterior shoulder dislocation with an impression fracture involving less than 25% of the humeral head were treated by open reduction together with posterior cruciate capsular repair as described by Neer. The patients' average age was 48.5 years (range, 32.5-66 years). There were 14 men and 3 women. The dominant shoulder was affected in 14 cases. RESULTS: After a minimum follow-up of 5 years (range, 5-10 years), the average UCLA score improved from 18 preoperatively to 33 postoperatively. The average modified Rowe score changed from 42.2 to 78.4 points. The American Shoulder and Elbow Surgeons Shoulder score showed an average of 40.3 points preoperatively and an average of 79.8 points at final follow-up. Three patients developed late osteoarthritic changes. Two had changes of mild degree, and 1 needed a total shoulder replacement. CONCLUSION: Open reduction with posterior cruciate capsular repair offers a good solution for the problem of neglected unreduced posterior shoulder dislocation excluding cases with osteoarthritic changes and those with impression fracture involving less than 25% of the head.