Management of clubfoot deformity in amyoplasia.

Forty-one clubfeet in 22 patients with amyoplasia were studied retrospectively at a mean duration after surgery of 118 months (range, 45-253). The clubfeet were managed by a regimen including initial stretching casts, posteromedial release, and postoperative splinting at night. The mean age at the time of surgery was 7.3 months. Correction of deformity without recurrence was achieved in 11 (27%). Recurrent deformity was corrected by serial casting in eight feet and required secondary operative procedures in 20 feet. In the feet without recurrence of deformity, the duration of splinting at night after surgery was significantly longer than in those with recurrence (p < 0.05). At follow-up, 39 (95%) feet were plantigrade and were considered satisfactory. Our findings suggest that most clubfeet in amyoplasia can be effectively corrected by posteromedial release and that the recurrence of deformity can be reduced by splinting at night and often corrected by serial cast treatment.

Orthopaedic manifestations of invasive group A streptococcal infections complicating primary varicella.

The incidence of invasive group A streptococcal (GAS) infections in primary varicella appears to be increasing. GAS infections complicating varicella range from cellulitis, abscess, and septic arthritis to life-threatening necrotizing fasciitis and pyomyositis in association with GAS toxic shock syndrome (TSS). Four patients admitted in 1 year to the Children's Hospital and Medical Center in Seattle, whose care included evaluation and treatment by the Orthopaedic service, are presented to illustrate this spectrum. Three had a delay in diagnosis, including discharge from previous emergency department visits. One patient with polyarticular septic arthritis was treated with diagnostic aspiration and intravenous antibiotics. The remainder required urgent surgical debridement for treatment of deep infection. Patients with necrotizing fasciitis or pyomyositis had life-threatening complications of TSS, including hypotension, adult respiratory distress syndrome (ARDS), coagulopathy, and acute renal failure. These patients required aggressive fluid resuscitation and prolonged intensive care unit support. Diagnostic imaging studies were obtained in one patient with necrotizing pyomyositis but may have served only to delay definitive treatment. Recognition of the potential for secondary GAS infections and a high index of suspicion for the presence of necrotizing soft-tissue infection are essential in the evaluation of any child with fever and localized extremity pain with varicella.

Calcaneal lengthening for valgus deformity of the hindfoot. Results in children who had severe, symptomatic flatfoot and skewfoot.

Thirty-one severe, symptomatic valgus deformities of the hindfoot in twenty children who had flatfoot (twenty-five feet) or skewfoot (six feet) were corrected with a modification of the calcaneal lengthening osteotomy described by Evans. Despite prolonged non-operative treatment, all patients had pain, a callus, ulceration, or a combination of these signs and symptoms under the head of the plantar flexed talus; they could not tolerate a brace, and shoe wear was excessive. Twenty-six of the deformities were secondary to an underlying neuromuscular disorder. The calcaneal lengthening was combined with an opening-wedge osteotomy of the medial cuneiform to correct the deformities of both the hindfoot and the forefoot in the patients who had a skewfoot. Other concurrent osseous and soft-tissue procedures were frequently performed in the flatfeet and skewfeet to correct adjacent deformities or to balance the muscle forces. Allograft bone was used in twenty-four feet and autogenous bone, in seven. The patients ranged in age from four years and seven months to sixteen years at the time of the operation. The duration of follow-up ranged from two years to three years and seven months after the operation. Satisfactory clinical and radiographic correction of all components of the deformity of the hindfoot was achieved in all but the two most severely deformed feet. These two feet had sufficient correction to eliminate the symptoms despite a small persistent callus under the head of the talus. The pain and callus were eliminated in all of the other feet, the patients were able to tolerate a brace, and shoe wear was improved. Subtalar motion was preserved in all feet except for the four that had had a limited joint arthrodesis performed previously or simultaneously for pre-existing degenerative osteoarthrosis. Calcaneal lengthening is effective for the correction of severe, intractably symptomatic valgus deformities of the hindfoot in children. My patients had resolution of the signs and symptoms associated with the deformity while avoiding the need for an arthrodesis and the many short and long-term complications associated with it.

Fracture of the cuboid in children. A source of leg symptoms.

We report eight cases of fracture of the cuboid in seven children under four years of age, collected during a two-year period. There was no history of trauma in five of the patients. This fracture is rarely diagnosed and has probably been under-reported. Small children are poor historians and difficult to examine, and early radiographs may be normal or have only subtle abnormalities. Cuboid fracture should be considered in the differential diagnosis of limping toddlers, and a bone scan may be needed to confirm the diagnosis earlier than radiography. These fractures heal completely, without sequelae. Treatment in a short-leg walking cast is recommended, primarily for reasons of comfort.

Ambulatory outcome of children with myelomeningocele: effect of lower-extremity muscle strength.

The relationship between patterns of strength and mobility was studied in 291 children with myelomeningocele, graded as community ambulators, partial (household) ambulators and nonambulators. Iliopsoas strength was found to be the best predictor of ambulation, with the quadriceps, anterior tibialis and glutei also contributing significantly. Grade 0 to 3 iliopsoas strength was always associated with partial or complete reliance on a wheelchair. No patient with grade 4 to 5 iliopsoas and quadriceps function relied completely on wheelchairs and the majority were community ambulators. Grade 4 to 5 gluteal and anterior tibialis function was associated with community ambulation, without aids or braces. Deterioration in mobility was most common in those with strong iliopsoas/quadriceps and grade 0 to 3 gluteus medius, and was not age-related.

Pitfalls in diagnosis: the hip.

The hip joint is unique anatomically, physiologically, and developmentally. Because of these features, diagnosis of pathologic conditions is more difficult than for most joints. Because delay in diagnosis and treatment may result in crippling osteoarthritis, it is imperative that diagnostic pitfalls be avoided.

Medial femoral torsion and osteoarthritis.

We investigated the hypothesis that medial femoral torsion is a predisposing factor to osteoarthritis of the hip. Anteversion was measured by biplane radiography in 44 hips (32 patients) with idiopathic osteoarthritis of the hip and a control group of 98 normal hips (49 adults). The mean and range of anteversion measures were similar in both groups. The mean was 22 degrees for osteoarthritic hips (range 3 degrees-49 degrees) and 19 degrees for normal controls (range -2 degrees-49 degrees). This difference was not significant. This study disagrees with others that propose an association between increased anterversion and osteoarthritis of the hip. Prophylactic operative correction of femoral torsion for osteoarthritis is not recommended.

Management of hip dislocations in children with arthrogryposis.

From a review of 131 children with arthrogryposis, we studied 18 patients with hip dislocations. Fourteen patients (10 unilateral, four bilateral) were treated by open reduction. Mean age at surgery was 9.7 months, and follow-up ranged from 9 to 245 months. Range of motion of patients treated by open reduction following the medial approach was greater than in those treated by anterolateral incision and greater than in bilateral cases treated by closed reduction. Acetabular development was satisfactory following the medial approach and there were no re-dislocations, but one hip developed avascular necrosis.