Late results of subtalar distraction fusion.

Between 1990 and 1994, 15 subtalar distraction fusions were performed on 14 patients for sequelae of calcaneus fractures. Twelve patients (13 feet) were available for a minimum 2-year follow-up and constituted the composition of this study. All patients complained of lateral ankle pain and had CT evidence of calcaneofibular abutment and radiographic evidence of loss of heel height preoperatively. The average age at time of surgery was 56 years (range, 23-81 years), and the average follow-up was 47 months (range, 25-75 months). The only change in surgical technique from that previously described was the use of a bone spreader rather than a femoral distractor for distraction of the subtalar joint. The average preoperative talocalcaneal angle improved from 27 degrees range, 19-37 degrees) to 33 degrees (range, 23-45 degrees) postoperatively (P < 0.003). The mean talar declination angle improved from 11 degrees (range, 6-18 degrees) to 16 degrees (range, 7-27 degrees) postoperatively (P < 0.003). The mean heel height increased from 71 mm (range, 60-83 mm) to 76 mm (range, 63-91 mm) postoperatively (P < 0.0001). All patients completed the AOFAS Ankle-Hindfoot scale at latest follow-up, and the average score was 76.1 (range, 57-94). Eleven of 13 outcomes were rated as very satisfactory or satisfactory. Twelve of 13 said they would 'definitely yes" do surgery again. We have found that subtalar distraction fusion for late complications of calcaneus fracture in a carefully selected population can provide a consistent and satisfactory outcome.

Epiphysiodesis of the lower extremity: results of the percutaneous technique.

The results of 42 percutaneous epiphysiodeses of the lower extremity in 26 patients are reported. All patients achieved physeal arrest radiographically and clinically. No patient developed angular deformity from incomplete arrest. No neurovascular complications or fractures occurred. The average hospital stay for patients undergoing epiphysiodesis alone was 1 day. Percutaneous epiphysiodesis of the lower extremity provides a reliable and safe technique for growth plate arrest. The advantages of this technique include a cosmetic scar, short hospital stay, low incidence of complications, and reliable physeal arrest.

Triple arthrodesis with lateral column lengthening for treatment of severe planovalgus deformity.

Triple arthrodesis with lateral column lengthening through the calcaneocuboid joint was performed on 22 feet in 14 patients. The primary indication for surgery was severe symptomatic planovalgus deformity unresponsive to conservative measures. All patients achieved solid fusion within 12 weeks. No patient had no decline in ambulatory status. Excellent correction of deformity was achieved and maintained with an average correction of the talus first metatarsal angle of 25 degrees in both the AP and lateral planes. Triple arthrodesis with lateral column lengthening provides for reliable arthrodesis and allows correction of severe planovalgus deformity while maintaining foot length.

Joint reaction forces during femoral lengthening.

The purpose of this study was to observe the reactive force across the hip and knee joint in a cadaver study during simulated femoral lengthening. Load cells were placed in the hip and knee joints while force measurements were taken after every 1 mm of lengthening. The lengthening was performed on one side with a distal osteotomy and on the other with a proximal osteotomy to determine if the level of the osteotomy had any affect on the forces across the proximal and distal joints. The study showed that the forces at the hip and knee joints increased during lengthening. The proximal osteotomy appeared to increase the amount of force at the hip joint. The force at the knee joint was less affected by the level of the osteotomy. The relative force between the knee and the hip was approximately a 2:1 ratio with a distal corticotomy as opposed to a 1:1 ratio with a proximal osteotomy. From this study, it is suggested that if instability of the hip is a concern during femoral lengthening, then a distal osteotomy should be used.

Deformity correction and arthrodesis of the midfoot with a medial plate.

Nine feet in eight patients undergoing tarsometatarsal (Lisfranc) or other midfoot arthrodeses for posttraumatic or degenerative arthritis were reviewed retrospectively. All patients were treated using a medial one-third tubular plate spanning the midfoot joints to be fused. Three feet underwent fusion in situ while six feet underwent correction of residual planus, planovalgus, or cavovarus deformity at the time of fusion. All patients achieved fusion within 12 weeks. A good or excellent result was achieved in seven of nine feet. There was no radiographic or clinical evidence of pseudarthrosis or medial hardware failure in any patient. No patient to date has required hardware removal for a painful or prominent implant. The talus first metatarsal angle was improved an average of 15.5 degrees in the lateral plane and 10 degrees in the AP plane in patients undergoing deformity correction. The technique of using a medial plate for midfoot arthrodesis allows for reliable fusion in patients who require salvage for midfoot arthritis. This technique also allows for correction of deformity in patients with residual midfoot deformity.

Effects of splitting the iliac apophysis on subsequent growth of the ilium: a rabbit study.

We wished to determine if splitting the iliac apophysis in a skeletally immature animal would affect subsequent growth of the ilium. Thirty-two rabbits were divided into six groups. One group was the sham group; the other five groups received different types of surgical splitting and repair of the iliac apophysis. The results suggested that any splitting of the iliac apophysis in an immature animal significantly affects subsequent growth of the ilium. The type of repair apparently does not affect the amount of growth retardation. Using electrocautery to split the iliac apophysis has a significantly greater effect on growth of the ilium.

Three additional cases of focal fibrocartilaginous dysplasia causing tibia vara.

Three additional cases of unilateral tibia vara caused by focal fibrocartilaginous dysplasia are reported in children aged 5, 6, and 18 months. These three cases support the conclusion of our original case report that unilateral tibia vara is most likely a progressive deformity, but that documentation of the progression should be obtained before a valgus osteotomy is performed.

Monteggia and equivalent lesions in childhood.

One hundred two children with acute Monteggia lesions treated over a 25 year period were reviewed. Using the Bado classification system, type 1 (53%) and type 3 (26%) fractures were the most common. The type 1 equivalent injury associated with a proximal radius fracture is more common in children than previously reported. The majority of injuries could be treated with closed reduction, except the type 1 equivalent lesions, which required operative treatment in 10 of 14 children. Varus angulation of the ulna was the most common deformity after closed treatment. Nerve injuries occurred in 11% of the injuries, and resolved in all cases without operative treatment.

Tibial shortening for leg length discrepancy.

Over a 25-year period, 12 patients had from 2.5 to 5.1 cm operative shortening of the tibia and fibula for leg length discrepancy at between four and 18 years of age. All recovered normal function and there was minor cosmetic impairment in only two cases. The only vascular complication was temporary delay in return of the circulation to the foot after tourniquet removal in one patient. The procedure is valuable for discrepancy of tibial length in patients when they present too late for epiphyseal arrest, when there is doubt as to the appropriate timing for epiphyseal arrest, or when it is uncertain at an earlier stage whether there is need for surgical correction.

Outpatient treatment of upper extremity injuries in childhood using intravenous regional anaesthesia.

Intravenous (i.v.) regional anaesthesia was used in outpatient treatment of 400 upper extremity fractures and dislocations in children ranging in age from 3 to 16 years. All reductions were performed in the emergency department. Good analgesia was achieved in 90% of the patients, and only nine children (2.3%) had unacceptable reductions that required further treatment under general anaesthesia. Intravenous regional anaesthesia is a safe and effective procedure that facilitates outpatient treatment of upper extremity injuries in children.

Treatment of spastic equinus by aponeurosis lengthening.

The aponeurosis lengthening described in this study was performed on 156 patients (219 procedures) with spastic equinus deformities. There was only one wound complication and no calcaneus deformities from overlengthening. The recurrence rate requiring relengthening was high (48% of the procedures), particularly if the initial operation was performed before the age of 5 years. The length of postoperative immobilization did not affect the recurrence rate. The aponeurosis lengthening technique described is a simple lengthening of the aponeurosis, leaving the soleus largely intact without the use of internal sutures. It has a negligible complication rate, but a high rate of recurrent equinus.

Triple arthrodesis of the foot in spina bifida patients.

The feet of 13 spina bifida patients who had undergone triple arthrodesis in adolescence were reviewed at an average of 10 years after operation. Fifteen of 18 feet were considered satisfactory (83%); of the remaining three, two had recurrent planovalgus deformities and one a painful pseudarthrosis. Three feet had required revision of the triple arthrodesis, and there was one postoperative infection. No patient had lost ambulatory status as a result of foot problems and eight of the 10 patients who previously needed calipers were able to discard them or to use lighter ones.

Risk of iatrogenic septic arthritis in the presence of bacteremia: a rabbit study.

This study of rabbits determined the risk of producing iatrogenic septic arthritis by arthrocentesis in the presence of bacteremia. In bacteremic animals, three of 20 knees became infected following joint aspiration, and six of 20 knees became infected on injection of 0.2 ml of bacteremic blood. Spontaneous joint sepsis did not develop, even in bacteremic animals. Prophylactic cefazolin before joint aspiration prevented the development of iatrogenic septic arthritis but did not prevent the recovery of bacteria from an infected joint. Therefore, there is an increased risk of development of joint sepsis in this animal model following a traumatic aspiration in the presence of bacteremia. This risk can be minimized by intravenous antibiotics without decreasing the likelihood of recovery of an organism if the joint is septic.

Excision of symptomatic coalition of the middle facet of the talocalcaneal joint.

From 1977 through 1984, nine patients who had ten persistently symptomatic coalitions of the middle facet of the talocalcaneal joint were treated with excision of the coalition and an autogenous free fat graft. Evaluation revealed five excellent, three good, one fair, and one poor result, with an average length of follow-up of forty-two months after surgery. The patient (one foot) with the fair result initially had a poor result until revision, at which time incomplete resection was documented. The patient (one foot) with the poor result initially had a fair result, but it deteriorated forty months postoperatively. Incomplete resection at the time of the initial operation was documented at the time of the second operation. Functional testing of these patients revealed results that were comparable with the results that have been reported after resection of calcaneonavicular coalition. [corrected]

Combined innominate and femoral osteotomy for the treatment of severe Legg-Calvé-Perthes disease.

Nine patients who underwent combined innominate and femoral osteotomy for the treatment of Legg-Calvé-Perthes disease were evaluated. All had Catterall group III or IV involvement, the average number of radiographic "head-at-risk" signs was 3.2, and the average epiphyseal extrusion was 26%. At an average follow-up of 50.5 months, the clinical results were seven good and two fair. The radiographic results were four good, four fair, and one poor. We believe this procedure is indicated in the older patient with severe Perthes disease in whom femoral head subluxation or deformity makes containment difficult or impossible by more conventional methods.