Pelvic obliquity and the unstable hip after poliomyelitis.
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Child, Preschool↗
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Proximal femoral resection to allow adults who have severe cerebral palsy to sit.
Resection of the proximal end of the femur and interpositional arthroplasty was done in thirty-four patients (fifty-six hips) to allow the patients to sit comfortably and to make perineal care painless. All of the patients were severely handicapped because of cerebral palsy, were unable to walk, and were residents of one of two state institutions. After a minimum follow-up of two years, the result had not deteriorated in thirty-three of the thirty-four patients.
Adolescent↗
Passive moment about the hip in straight leg raising.
OBJECTIVE: The purpose of this examine is to study the load-deformation characteristics of the hip in straight leg raising. DESIGN: An experimental study in which passive moment about the hip was determined as a function of hip angle. BACKGROUND: Straight leg raising is widely employed in clinical examination, and there is little information on its mechanical characteristics. METHODS: Fourteen healthy volunteers were recruited for this study. Three trials of straight leg raise tests were performed while subjects lay supine on a plinth that was fitted with load cells. An electrogoniometer was employed to measure hip flexion during the test. Resistive moment at the hip was determined using a dynamic biomechanical model. RESULTS: The present experimental method was shown to be highly reliable. The moment-angle curves of all subjects were shown to follow an exponential function. CONCLUSION: Stiffness and strain energy of posterior hip tissues could be derived from the moment-angle curves. Evaluation of such elastic properties is clinically important as they may be altered with injuries of the tissues. RELEVANCE: Clinically, contracture of hamstring muscles and other posterior hip tissues is evaluated by measuring the available range of hip flexion in straight leg raising. However, this does not provide any information on the elastic properties of the tissues. The present study reports a reliable method of evaluating such properties.
Adult↗
Hip joint instability after the neonatal period. Diagnosis and treatment of 20 consecutive cases.
A consecutive series of 20 children (21 hips) with idiopathic hip joint instability, diagnosed after the neonatal period, is presented. The diagnosis was confirmed by hip joint arthrography. In all the children, 1.5-21 months old at the time of diagnosis, closed reduction could be achieved. They were treated in plaster directly or after treatment of contractures in the adductor muscles of the hip joint. Stability was rapidly attained during plaster treatment. The results of the treatment in plaster were checked by a second arthrography in two thirds of the cases, and all cases have been clinically and radiologically evaluated 1-4.5 years after diagnosis. All of the children developed clinically stable hips and they walk normally. In two hips signs of avascular necrosis of the femoral head were found and in three hips (two children) the skeletal development was markedly delayed. In 81 per cent (17/21 hips) the prognosis was considered good; it is uncertain in the remaining four hips. The appropriate period of fixation in plaster related to the age of the child is discussed.
Casts, Surgical↗
Contractures in burn injury: defining the problem.
This study prospectively examined the incidence and severity of large joint contractures after burn injury and determined predictors of contracture development. Data were collected prospectively from 1993 to 2002 for consecutive adult burn survivors admitted to a regional burn center. Demographic and medical data were collected on each subject. The primary outcome measures included the presence of contractures, number of contractures per patient, and severity of contractures at each of four joints (shoulder, elbow, hip, knee) at time of hospital discharge. Logistic regression analysis was performed to determine predictors of the presence and severity of contractures and a negative binomial regression was performed to determine predictors of the number of contractures. Of the 985 study patients, 381 (38.7%) developed at least one contracture at hospital discharge. Among those with at least one contracture, the mean is three contractures per person. The shoulder was the most frequently contracted joint (38%), followed by the elbow (34%) and knee (22%). Most contractures were mild (60%) or moderate (32%) in severity. Statistically significant predictors of contracture development were length of stay (P < .005) and extent of burn (P = .033) and graft (P < .005). Predictors of the severity of contracture include graft size (P < .005), amputation (P = .034), and inhalation injury (P = .036). More than one third of the patients with a major burn injury developed a contracture at hospital discharge, which highlights the importance of therapeutic positioning and intensive therapy intervention during acute hospitalization. Furthermore, this challenges the burn care community to find new and better ways of preventing contractures after burn injury.
Adult↗
The role of trochanteric osteotomy in total hip replacement.
In a study of 225 hip replacements, 126 had trochanteric osteotomy and 99 did not. Trochanteric osteotomy was found to be invaluable in approaching the difficult, previously operated hip. Even though 81 hips without trochanteric osteotomy had no complications directly related to the operative technique, 19 had significant operative problems. Hips with fixed flexion or external rotation contractures preoperatively presented technical difficulties and postoperative problems avoidable only by trochanteric osteotomy. Complications are encountered with and without osteotomy and various indications for osteotomizing the greater trochanter through a lateral approach to the hip are reviewed on the basis of experience with 184 patients with an average age of 61 years.
Adult↗
Orthopedic surgical management of hip and knee involvement in patients with juvenile rheumatoid arthritis.
Juvenile rheumatoid arthritis is the most common arthritic disease of childhood and a leading cause of childhood disability, affecting an estimated 300,000 US children and adolescents aged < or =16 years. Approximately 10% to 30% of patients experience functional deficits resulting from both the articular and systemic manifestations of their disease, including leg length inequality and deformity, that are often more crippling than joint destruction. Surgical intervention to treat bone and soft-tissue deformity, leg length inequality, and joint destruction is indicated when medical therapy has failed. Synovectomy, soft-tissue release, osteotomy, and epiphysiodesis are used to treat deformity and early joint destruction. Arthroplasty remains the primary therapy for joint destruction, although it is fraught with complications specific to this young patient population.
Arthritis, Juvenile↗
Spinal cord injury in children.
The spinal injured child has speical needs owing to the processes of physical, mental and social growth. Goals of physical treatment programs include prevention of: genitourinary complications; contractures; pressure sores; long bone fractures, hip subluxation and dislocation; spinal deformity. Nonoperative treatment of spinal deformity employing external support should be initiated when the potential for spinal deformity exists. External support delays the development of spinal deformity, improves sitting balance and allows free upper extremity use. The overall treatment programs must consider altered body proportions, immaturity of strength and coordination. Case examples of children with spinal injury are presented above to illustrate specific problems stemming from immaturity of physical, cognitive, and social development. Spinal surgery can be a conservative measure in the growing child when there is radiologic evidence of progressive spinal deformity. Posterior spinal fusion with Harrington instrumentation and external support permits immediate return to vertical activity.
Adolescent↗
Distal rectus femoris transfer.
A major concern in the management of children with cerebral palsy is crouch gait with its excessively flexed knee and hip stance. Earlier, attention was given to the flexed hip and it was assumed that the rectus femoris, as an active component of the quadriceps, contributed an unwanted effect. Proximal surgical release of the rectus from its attachment on the ilium was recommended. However, dynamic electromyographic records of 45 children with cerebral palsy demonstrated that the rectus more commonly was active in the swing phase, and such an approach is appropriate only when electromyography confirms that rectus function is occurring in stance. The recording technique must be capable of differentiating rectus femoris action from that of the underlying vasti, which surface electrodes are not able to do. Past experience indicates that routine inclusion of a proximal rectus femoris release (without confirmation that the muscle's action was limited to stance) resulted in the patient having a stiff-legged gait. Hence the actions of the rectus femoris need closer attention.
Cerebral Palsy↗
Psoas over the brim lengthenings. Anatomic investigation and surgical technique.
Lengthening of the psoas tendon commonly is performed for various conditions of the hip including developmental dysplasia and neuromuscular contractures and instability. Anecdotal reports of injury to surrounding neurovascular structures suggest an investigation of the local anatomy is warranted. Using magnetic resonance images from 54 children younger than 10 years, the authors examined the anatomic relationship between major neurovascular structures (femoral artery and vein, external iliac artery and vein, femoral nerve) and the psoas tendon. The mean distance between the neurovascular structures and the psoas tendon in the over the brim position is 1 cm, although it may be as close as 4 mm in a child. The mean distance is 3.1 cm at the tendon's insertion at the lesser trochanter. Surgeons performing psoas over the brim lengthenings should be aware that major neurovascular structures may be only 4 mm from the psoas tendon. The recommended surgical technique is presented.
Cadaver↗
[Medial rotation deformity of the hip in cerebral palsy: surgical treatment by transposition of gluteal muscles].
INTRODUCTION: Medial rotation deformity of the hip is a problem to patients who are handicapped by cerebral palsy but able to walk, because the knees point inward during gait ("kissing patellae") and cause falls and frequent injuries. Knees and ankles are subject to stress and, therefore, they assume compensating positions. Lower legs assume position of valgus and external rotation, whereas feet rotate either inwards or outwards. Secondary deformities make gait more difficult and cause rapid tear of footwear. AIM: The purpose of the paper was to retrospectively analyze the effects of transposition of the gluteus medius and minimus muscles, a procedure introduced for the first time in our country in order to correct the deformity. A new method of binding the muscles by wire was described. There had been no previous experience with this method. METHOD: This operation was indicated in patients with spastic form of cerebral palsy, who were able to walk, who had difficulties in gait and whose lateral rotation was less than 10 degrees along with the medial rotation of over 70 degrees of the hip on the side of the deformity. Additional prerequisite for the operation was the absence of flexion contracture of more than 15 degrees of either the hip or the knee on the side of deformity, as there is possibility of aggravation of the flexion hip deformity due to transposed gluteal muscles (now in front of the hip joint). Fifteen hips of 10 patients were operated on. Five patients were operated on bilaterally at one time. The average age was 8 (6-12) years. The majority of patients, 8 (80%) were aged between 6 and 8. The average follow-up was 5 years (3-8). The assessment of the results was based on the comparison of rotational abilities of both hips before and after the operation (in unilateral and bilateral deformities), as well as on individual complaints before and after the operation. In patients with unilateral deformity, their "healthy" hips were the control hips. The analysis of the femoral neck anteversion before and after operation was performed. RESULTS: Average values of medial and lateral rotation of the deformed hips before operation exhibited significant statistical difference when compared to control hips. The difference of average values of rotatory movements of control and operated hips was not statistically significant after operation. The difference of average preoperative values of the femoral neck anteversion in hips with deformity was statistically significant (49.40+/-4.63 degrees compared to 32.8+/-3.11 degrees ). Postoperative average values of anteversion in operated and control hips were not statistically significant. The difference between average preoperative (49.40+/-4.63 degrees ) and postoperative (35.80+/-7.66 degrees ) values of the femoral neck anteversion was statistically significant. Excellent results were achieved in 5 (50%) patients, i.e. 8 (53.3%) hips; good results were achieved in 3 (30%) patients, i.e. 5 (33.3%) hips; poor result in 2 (20%) patients, i.e. 2 (13.3%) hips. All 5 patients who had undergone surgery of both hips had symmetric outcome. Three patients had excellent results, while two had good results. Patients with excellent and good results (80% of patients, 86.6% of hips) showed neither weakening of the operated hip abduction nor pelvic instability (positive Trendelenburgh hip test). No complications were recorded postoperatively. CONCLUSION: Transposition of gluteal muscles can be recommended in patients under 10 years of age as there is still a chance for their femoral neck to change orientation, to decrease the anteversion and thus to achieve long-lasting effect. Fixation of transposed muscles by wire proved to be effective.
Buttocks↗
Clinical variability in congenital fiber type disproportion.
Congenital Fiber Type Disproportion (CFTD) has recently been described as a consistent and stereotyped clinicopathological entity, including congenital nonprogressive hypotonia and weakness, contractures, kyphoscoliosis, high arched palate, dislocated hips, short stature, and feet deformities. Our personal experience with this condition suggests a wider disparity in the physical appearance and associated abnormalities of affected individuals than the well-defined clinical syndrome previously described. We are presenting 5 cases, including 2 siblings, whose muscle biopsies satisfy the major histological and statistical criteria for the diagnosis. Although each child clearly had hypotonia and weakness consistent with a congenital myopathy, only 3 had a sufficient number of other similarities to establish the diagnosis clinically. The clinical spectrum of the other cases ranged from one infant whose only abnormality was mild hypotonia in the legs to another whose problems included severe motor impairment, marked mental retardation, growth failure, frontal bossing, abnormal hair, and scoliosis. Even in retrospect, the diagnosis of CFTD could not have been supported on clinical grounds alone. Therefore, CFTD is a congenital myopathy whose diagnosis can be made only by muscle biopsy, rather than a distinct syndrome whose diagnosis can be assumed on the basis of clinical characteristics alone.
Child, Preschool↗
[Etiology of fixed lumbar lordosis: the lumbar dermoid].
Following a general survey of fixed lumbar lordosis the dermoids, in particular lumbar dermoids and their role in fixed lumbar lordosis, are described. Intralumbar dermoids must be regarded as a genuine rarity. The occurrence of fixed lumbar lordosis may be an early symptom. After radical removal restitutio ad integrum is possible. If any portion is left in situ the risk of recurrence is high. Follow-ups over a number of years are therefore mandatory.
Child↗
Epidemiology of spastic tetraplegic cerebral palsy in Sweden. I. Impairments and disabilities.
Ninety-six children and adolescents, born in 1959-78, with spastic tetraplegic cerebral palsy (TPL) were studied in terms of impairments and disabilities. The series was population-based and derived from 15 Swedish counties, and the city of Gothenburg, a population of 4.5 million people in all. All the patients had a pronounced motor disability with severe spastic pareses of all four limbs, and all of them were severely mentally retarded. None of them could speak. Ninety-four percent had epilepsy, 47% were severely impaired visually. Additional impairments were hip luxation(s) in 75%, severe contractures in 73% and scoliosis in 72%. Sixty-eight percent of cases had secondary microcephaly; 13% were born microcephalic. - The general uniformity of the severity and multiplicity of the impairment and disability pattern is emphasized - making the TPL group suitable for scientific care load studies on the basic requirements for the care of the profoundly retarded with maximum multi-handicaps.
Adolescent↗
The iliotibial band--a malignant structure masquerading as benign.
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Child↗
SURGERY OF THE LOWER EXTREMITY IN RHEUMATOID ARTHRITIS.
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Arthritis, Rheumatoid↗
Musculoskeletal manifestations of Proteus syndrome: report of two cases with literature review.
Proteus syndrome is a recently described hamartomatous condition characterized by macrodactyly, hemihypertrophy, subcutaneous (s.c.) tumors, epidermal nevi, and skull anomalies. Two new cases are described to illustrate the diagnostic features and the orthopedic problems associated with this rare syndrome. Review of available literature shows that 61 patients with proteus syndrome commonly develop macrodactyly, limb overgrowth, spinal deformity, hip dysplasia, genu valgum, exostoses, joint contractures, and hindfoot deformities.
Adolescent↗
Amyoplasia (a common form of arthrogryposis).
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Adolescent↗