Measurement of isolated subtalar range of motion: a cadaver study.

Fifteen fresh-frozen cadaveric lower extremities were studied to evaluate the reliability of measuring subtalar motion using a bubble inclinometer. There was high intra-observer reliability for manual inversion and eversion of the subtalar joint with the tibiotalar joint locked and unlocked. Poor correlation of radiographic and clinical measurements questioned the validity of bubble inclinometer measurements. The contribution of the tibiotalar joint to apparent subtalar motion, as measured clinically and radiographically, was found to be one-third of the arc of motion, as compared to motion measured clinically and radiographically with the tibiotalar joint locked.

A review of orthopedic injuries in three recent U.S. military conflicts.

We conducted a retrospective review of all patients with orthopedic injuries evacuated to a single medical center to evaluate the treatment and outcome of these injuries in three recent U.S. military conflicts: Operation Urgent Fury (Grenada), Operation Desert Shield/Storm (southwest Asia), and Operation Restore Hope (Somalia). Sixteen orthopedic casualties were originally treated at the medical detachment in Grenada before evacuation to the medical center. Most of these injuries were gunshot wounds to the extremities (11), with three known open fractures. Two patients (three extremities) sustained traumatic amputation (19% amputation rate). One hundred eighty-one patients with orthopedic injuries were medically evacuated from southeast Asia to the medical center for definitive treatment. Of these injuries, there were 143 fractures in 69 patients. One hundred of these fractures were open fractures, and 60% of these injuries were blast injuries. Furthermore, there were 26 amputations (14%). Twenty-two patients with orthopedic injuries were treated in Somalia and evacuated to the medical center. Thirteen of the 22 patients (59%) sustained gunshot wounds, and 2 (9%) sustained blast injuries. There were eight open fractures (36%) and three amputations in two patients (14%). Three of the 22 patients underwent successful limb salvage when ablation was the only other surgical alternative. It appears that a large percentage of medical center evacuations from military conflicts are for orthopedic injuries. Many of these injuries are the result of high-velocity weapons or blast injuries. Regardless of the size and/or purpose of the intervention, similar injury patterns and severity can be expected, because 51% of orthopedic patients had open fractures. Similarly, the rate of amputation associated with extremity trauma has not varied significantly since the Vietnam War.

Occult intraspinal anomalies in congenital scoliosis.

Thirty consecutive patients with congenital spinal deformity underwent magnetic resonance imaging (MRI) to determine the incidence of occult intraspinal anomaly. These congenital spinal deformities included 29 cases of congenital scoliosis and one case of congenital kyphosis. Physical examination findings and plain radiographs were reviewed in an attempt to correlate these findings with subsequent intraspinal pathology. Nine patients had intraspinal anomalies identified on MRI consisting of five with tethered cord, four with syringomyelia, three with lipoma, and one with diastematomyelia. One patient required surgery for diastematomyelia; another underwent release of his tethered cord. Only one patient, with diastematomyelia associated with a syrinx and bifocal tethering, had his anomaly suggested by physical examination and plain radiographs. Two other patients had findings on plain radiographs previously associated with high prevalence of occult intraspinal anomalies; one patient with congenital kyphosis had a tethered cord, and one patient with a unilateral hemivertebrae associated with a contralateral bar had a tethered cord. Two of nine patients with occult intraspinal anomalies required surgery for their anomaly. In patients with a congenital spinal deformity, we found nine (30%) of 30 to have an associated anomaly within the spinal canal. Only three of these nine had plain radiographs and physical examination findings suggestive of their subsequent MRI findings. Given the poor correlation between findings on physical examination, plain radiographs, and subsequent occult intraspinal anomalies on MRI, we believe that MRI is helpful in evaluating patients with congenital spinal anomalies.

Correction of ankle valgus deformity secondary to multiple hereditary osteochondral exostoses with Ilizarov.

The following case report highlights basic aspects of Multiple Hereditary Osteochondral Exostoses (MHOCE) and discusses the successful treatment of an adult with ankle pain secondary to growth arrest and foreshortening of the fibula. Two salient features include the age of the patient at presentation and the success of the procedure. Symptomatic valgus deformities of the ankle secondary to MHOCE are normally corrected during adolescence, prior to physeal closure. Reducing the ankle mortise by distally displacing the fibula and correcting rotational and angular ankle deformities with Ilizarov external fixation improved this patient's ankle function and relieved his pain.

Role of the peroneal tendons in the production of the deformed foot with posterior tibial tendon deficiency.

Ten patients were identified with traumatic, complete common peroneal nerve palsy, with no previous foot or ankle surgery or trauma distal to the knee, who had undergone anterior transfer of the posterior tibial tendon to the midfoot. Six of these patients had a transfer to the midfoot and four had a Bridle procedure with tenodesis of half of the posterior tibial tendon to the peroneus longus tendon. Average follow-up was 74.9 months (range, 18-351 months). All patients' feet were compared assessing residual muscle strength, the longitudinal arch, and motion at the ankle, subtalar, and Chopart's joint. Weightbearing lateral X-rays and Harris mat studies were done on both feet. In no case was any valgus hindfoot deformity associated with posterior tibial tendon rupture found. It seems that the pathologic condition associated with a posterior tibial tendon deficient foot will not manifest itself if peroneus brevis function is absent.

Pedal manifestations of musculoskeletal disease in children.

Musculoskeletal disease presenting in a child's foot is usually an isolated mechanical problem rather than part of a systemic disease; however, the pediatric flatfoot may be a more serious problem, caused by tarsal coalitions, congenital vertical talus, or part of a syndrome. The most common congenital pediatric foot deformities, including flatfoot, talipes equinovarus, digital anomalies, and osteochondritis, have characteristic and easily identifiable features that should be familiar to the practitioner. In this article, these deformities are described as they occur in isolation and as the result of more serious syndromes or causes.

Pedal manifestations of musculoskeletal disease.

The major systemic musculoskeletal diseases that involve the foot include the inflammatory arthritides, gout, and diabetic osteoarthropathy. Podiatric problems are present in over one-third of patients with musculoskeletal disease and in over half of all patients with diabetes. The pedal manifestations of musculoskeletal disease are reviewed as the first indicators of systemic disorders and as they occur in established systemic diseases.

Bridle transfer for paresis of the anterior and lateral compartment musculature.

In the Riordan (bridle) transfer, the posterior tibialis muscle as motor is routed through the interosseous membrane and anastomosed into a "bridle" formed by the distal tibialis anterior and peroneus longus muscles. In theory, the bridle provides inversion/eversion balance even if the transfer effects only tenodesis. However, the procedure has been criticized because its insertion is not into bone. This review analyzes the use of bridle transfer in flaccid paresis involving musculature innervated by the peroneal nerve. Surgery was performed 1 to 3 years after injury for patients with traumatic etiology. Ten patients are reviewed at 61 months' mean follow-up. Eight patients had traumatic peroneal nerve loss. Two had neuromuscular etiology. Evaluation included review of records, telephone interviews, and physical examinations. Data on functional status included walking barefoot running, need for bracing, return to duty, and patient satisfaction. Physical examination recorded ankle position and motions, gait findings, and results of static electromyograms. All patients were able to walk barefoot, but 6 of 10 had a mild to moderate limp. Five patients returned to running initially; only two were able to keep running. Nine patients were brace-free initially (polio sequela required bracing initially), and four others returned to bracing. Of these, two experienced an acute "tearing" and dorsiflexion loss, one sustained a prolonged gradual loss of dorsiflexion, and one sustained a contralateral cerebrovascular accident. Only three of seven patients returned to active duty, and one is on jump status. All patients were satisfied with their initial result. Only two patients had no detectable swing phase problems (both returned to active duty). Five patients had peroneal nerve exploration with repair or neurolysis; two of them sustained complete transections. Postoperative electromyograms showed insignificant, if any, nerve return. The Riordan transfer works well for neuromuscular flaccid paresis and in patients with peroneal nerve injuries with low demands. It may stretch out over time to the point of acute failure in patients with high demands. Concurrent peroneal nerve exploration and repair did not seem to be beneficial in this small study.

Measurement of lumbar lordosis. Evaluation of intraobserver, interobserver, and technique variability.

STUDY DESIGN: Sixty radiographs were measured on two separate occasions by three physicians using four different techniques to evaluate the reliability and reproducibility of the measurement of lumbar lordosis. OBJECTIVE: To evaluate clinical methods of measuring lumbar lordosis, determining intraobserver and interobserver reliability. SUMMARY OF BACKGROUND DATA: Several different methods are used to measure lumbar lordosis. The reliability and reproducibility of these has not been well studied. METHODS: Sixty lateral full spine radiographs were obtained, labeled, and the lumbar lordosis measured independently by three practitioners who routinely perform these measurements. Four measurement techniques were used. These included measurements from the inferior endplate of T12 to the superior endplate of S1; the superior endplate of L1 to the superior endplate of S1; the inferior endplate of T12 to the inferior endplate of L5; and the superior endplate of L1 to the inferior endplate of L5. The measurements then were repeated after relabeling. RESULTS: Intraobserver reliability coefficients ranged from 0.83 to 0.92, indicating excellent reproducibility. Ninety-two percent of repeat measures were within 10 degrees. High overall and pairwise agreement among the three observers also was present; the interobserver reliability coefficients ranged from 0.81 to 0.92. CONCLUSIONS: The measurement of lumbar lordosis is reproducible and reliable if the technique is specified and one accepts 10 degrees as acceptable variation. Factors that affect the reproducibility of measurement include end vertebra selection (especially with transitional segments) and vertebral endplate architecture.

Acute rupture of the peroneal longus tendon in a runner: a case report and review of the literature.

Traumatic rupture of the peroneal longus tendon is rare and the diagnosis may be difficult. Swelling and tenderness about the lateral aspect of the ankle, increased hindfoot varus, and pain with active eversion are helpful clinical signs. Magnetic resonance imaging may be helpful in making the diagnosis. We present the case of a patient who sustained an acute rupture of the peroneal longus tendon. The tendon was repaired primarily and the patient was able to return to running. A high index of suspicion is required to prevent a delay in the diagnosis and further disability.

Percutaneous intramedullary fixation of long bone deformity in severe osteogenesis imperfecta.

Reported here are seven patients who had severe osteogenesis imperfecta, and who were extremely fragile, with three having cardiac disease. Their age ranged between 8 and 35 months. All seven patients had unbraceable deformities. Twenty five long bones, including 14 tibiae, 10 femora, and 1 ulna underwent percutaneous intramedullary fixation. Four patients had all four lower extremity long bones operated on simultaneously. Followup was 2 to 11 years. There were no neurologic or vascular complications, compartment syndromes, growth plate problems, or transfusion requirements. All bones healed. One patient had migration of a femoral pin into the knee joint. After bracing, all patients were able to sit; five were able to stand and eventually walk. All living patients were able to be sustained until successful definitive long bone fixation could be accomplished, approximately 2 years or longer after this initial procedure. With this safe, reproducible method, early stable fixation can be provided to patients too young and/or too sick for definitive or extensive open surgery. Future treatment regimens are not compromised.

A prospective evaluation of orthopedic patients evacuated from Operations Desert Shield and Desert Storm: the Walter Reed experience.

A prospective review of all orthopedic casualties received from the southwest Asia theater of operations during Operations Desert Shield and Desert Storm was carried out at Walter Reed Army Medical Center. An injury analysis of the 181 orthopedic patients revealed 143 total fractures in 69 patients, with the remaining patients sustaining soft tissue injuries from trauma, overuse, or pre-existing conditions. Seventy percent of the fractures were open, of which 23% were treated with external fixators and 41% eventually underwent an operative stabilization procedure. An analysis of the distribution of injuries is given as well as the incidence of amputations, nerve injuries, and arterial injuries. Early multidisciplinary involvement in the care of these casualties proved to be greatly beneficial.

Piriformis abscess mimicking a hip pyarthrosis.

Joint sepsis and osteomyelitis often give a confusing clinical picture in children because of the prevalent use of oral antibiotics for otolaryngeal disease, resulting in partially treated musculoskeletal infections. Unusual sites of infection must be considered when the patient does not respond to standard treatment. Recent scanning techniques can be useful in resolving this dilemma.

Efficiency in the pediatric orthopedic clinic and the effect on the parents: a comparison of military and civilian medical centers.

In a short-term comparison of similar pediatric orthopedic practices at a military and a civilian institution in the same geographical location, it was found that total appointment time, waiting time, and travel time were longer in the military setting. It appeared, however, that there was more leniency toward time off from work to accompany children to appointments in the military population. These factors may have considerable impact on time lost from the job for service member sponsors.

Treatment of residual clubfoot deformity--the "bean-shaped" foot--by opening wedge medial cuneiform osteotomy and closing wedge cuboid osteotomy. Clinical review and cadaver correlations.

Six patients (seven feet) previously treated surgically for clubfoot had a "bean-shaped" foot. Opening wedge medial cuneiform and closing wedge cuboid osteotomies were done, resulting in good resolution of the prominent midfoot supination and forefoot adductus without significant soft tissue dissection and invasion of growing areas in the foot. Cadaver reproductions show that the cuboid closing wedge is responsible for the change in the midfoot, whereas the cuboid and cuneiform osteotomies both contribute to the change in the forefoot.

Bilateral spontaneous arthrodesis of the hip after combined shelf acetabular augmentation and femoral varus osteotomies.

Spontaneous arthrodesis occurred after bilateral, extraarticular shelf augmentation and femoral varus osteotomies in a child with dislocated hips secondary to muscle imbalance from cerebral palsy. The proposed cause is heterotopic bone formation in the hip abductors in the face of insufficient range of motion exercise.

Treatment of the chronically dislocated hip in adolescents with cerebral palsy with femoral head resection and subtrochanteric valgus osteotomy.

Femoral head resection with valgus subtrochanteric osteotomy was performed on six hips in five nonambulatory adolescent patients with painful, chronically dislocated hips due to spastic paralysis. This procedure was successful because it led to pain relief, ease of perineal care, and facility of seating. Complications, such as proximal migration of the remaining femur, recurrence of adduction deformity, hip stiffness, and excessive heterotopic bone formation, common to other procedures used for this condition, have not occurred.