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PubMed1992

[Treatment of deformities of the locomotor system in hemiplegia].

In spastic hemiplegia mainly one side of the body is affected. In both the upper and the lower extremity the distal parts (hand and foot) are more severely involved than the proximal region. In cases of minor involvement the goal of treatment in the upper extremity is to achieve functional improvement by means of splinting and surgery. In cases of severe alterations cosmetic improvement without much functional gain is all that can be expected. Gait analysis has demonstrated that there are four basic patterns that can be related to the severity of involvement. In type I muscle imbalance exists without a contracture. In type II there is contracture of the muscles of the posterior compartment of the calf. In type III, in addition to the changes around the ankle joint, contractures around the knee are present, and in type IV also hip problems. Functional improvement can be achieved by means of splinting and surgery in all types. Basic principles of treatment have developed as a result of the application of gait analysis and dynamic electromyography. Specific examples of such treatment principles have recently been presented by Gage.

Child↗
PubMed1993

[Genu flectum in cerebral palsy, elongation of the flexors of the knee joint and our modification].

The authors evaluate the results of prolongation of the flexors of the knee joint in 175 patients with a flexed position of the knee joint associated with the spastic form of cerebral palsy. They draw attention to the interrelationship of the position of the lower extremities in the area of the sole, knee and hip joint and emphasize the necessity of correct assessment of primary contractures. They emphasize also the evaluation of correct concurrent function of flexors and extensors of the knee and their balanced functioning. The authors prefer a single surgical operation in combined affections of the lower extremities to the system of so-called minor steps. They emphasize the importance of postoperative rehabilitation and prosthetic support. In the authors' opinion surgery of the knee joint in manifestations of cerebral palsy on the lower extremities is the most controversial area associated with the highest percentage of failures and complications. Contrary to data in the literature, they refute the necessity of capsulotomy of the knee joint and recommend their own modification how to treat severe forms of genu flectum spasticum.

Adolescent↗
PubMed1987

Hip replacement for adults with unreduced congenital dislocation. A new surgical technique.

Total hip replacement for adults with unreduced congenital dislocation presents a difficult problem because soft-tissue contractures usually prevent sitting at the normal anatomical level. Extensive soft-tissue division or a high-level acetabulum leads to reduced function and poor fixation of the components. We describe a new technique for hip replacement in such cases. The shortened abductors and flexors are released proximally and excision of the upper third of the ilium allows them to be repaired without tension, while providing bone graft to reconstruct the acetabular roof. We report 12 such replacements in 10 patients with good results and few early complications.

Acetabulum↗
PubMed1995

Retrograde femoral nailing between an ankylosed hip and a stiff knee.

We describe a case of retrograde nailing of a comminuted infraisthmal femur fracture between an ankylosed hip and a stiff knee stemming from heterotopic bone and soft-tissue contracture. A tibial nail directed through the medial femoral condyle was used. At 1 year follow-up the fracture has united anatomically, and the patient has been rehabilitated to his preinjury functional status.

Ankylosis↗
PubMed1994

Articulated distraction of the hip. Conservative surgery for arthritis in young patients.

Between 1979 and 1982, 80 patients with a variety of hip diseases were treated with articulated distraction of the hip. The patients ranged from nine to 69 years of age (mean, 34 years). The primary diagnoses were avascular necrosis, osteoarthrosis, and chondrolysis. A standard dynamic axial fixator with a single axis articulating unit was used to create a 5-mm joint space. The fixator allowed flexion and extension motion and remained in place for six to ten weeks. The follow-up period ranged from five to eight years. Assessment was performed by questionnaire, clinical, and radiographic review. The results were poor in 24 patients who were either older than 45 years of age or had a diagnosis of inflammatory arthropathy. Forty-two good results were found in the 59 patients younger than 45 years with osteoarthrosis, hip dysplasia, avascular necrosis, and chondrolysis. Only four patients older than 45 years of age had a good result. No serious complications occurred.

Adolescent↗
PubMed1983

Idiopathic chondrolysis of the hip.

The cases of nine patients (eleven hips) with idiopathic chondrolysis of the hip were studied. Seven of the patients were white and two were Hispanic. The age at onset ranged from eight to sixteen years (mean, 11.5 years). Four patients were boys and five were girls. All patients had a decreased passive range of motion of the hip, and radiographic examination showed regional osteoporosis, premature closure of the femoral capital physis, narrowing of the joint space, and lateral overgrowth of the femoral head on the neck. All laboratory examinations were negative for evidence of infection or rheumatoid arthritis. An arthrotomy was done in seven patients. Specimens of the synovial tissue showed no growth on culture, and the histological studies revealed only minimum signs of inflammation. Histological studies of the articular cartilage were normal. Treatment consisted of administration of acetylsalicylic acid in therapeutic dosages to maintain a blood salicylate level of fifteen to twenty-five milligrams per cent, active non-loading exercise of the hip, protected weight-bearing with crutches, short-term traction to overcome or relieve contractures after biopsy, iliopsoas tenotomy or lengthening in three patients, and an adductor myotomy in one patient. At follow-up, 2.3 to 9.4 years after onset (mean, 6.2 years), six patients had either no symptoms or only minor intermittent discomfort in the hip. On radiographic examination, although these six patients had restoration of the joint space they did have lateral overgrowth of the femoral head (lateral buttressing) and overgrowth of the lateral acetabular margin (lateral osteophyte). In three patients who had disabling pain, joint deterioration was evident on the radiographic examination. One of these patients had a resurfacing arthroplasty to relieve pain.

Adolescent↗
PubMed1995

Femoral lengthening in patients having abnormal ipsilateral hip or knee.

Femoral lengthening using the Wagner technique was performed for 13 patients with abnormal adjacent joints. An average of 6.3 cm (19.5%) of lengthening was achieved. Three patients had no difficulties during lengthening. Transient non-surgical problems identified were blood pressure elevation, nerve palsy, and psychiatric reactions. Significant obstructions or complications occurred 13 times in nine cases. These included contractures of ipsilateral joints, angulations of the lengthened femur, Wagner device slippage, nonunion, and late hip subluxation. Other authors have reported similar difficulties in patients with normal ipsilateral joints. In this series, the advantage of achieving greater length appeared to outweigh the complications.

Adolescent↗
PubMedDate not supplied

Combined adductor transfer, iliopsoas release, and proximal hamstring release in cerebral palsy.

Twenty-two patients with cerebral palsy (CP) and progressive lateral migration of the hip who underwent a combined adductor transfer, iliopsoas release, and proximal hamstring release were reviewed retrospectively. The average age at surgery was 4 years 9 months, and clinical and roentgenographic follow-up averaged 21.9 and 19.2 months, respectively. Ninety-five percent of the patients demonstrated an improved range of motion. Roentgenographic analysis showed a statistically significant decrease in the migration percentage and the acetabular angle and an increase in the CE angle. We concluded that this procedure adequately addressed this complex problem, thereby limiting the number of hospitalizations and surgical procedures for this patient group. Longer follow-up will be necessary to determine if these results are maintained with time.

Adolescent↗
PubMed1987

Assessment and management of the lower extremity in myelodysplasia.

The goal in managing the lower extremity in a child with spina bifida is to achieve a pattern of development as near normal as possible. Lower limb deformities are produced by muscle imbalance, weight-bearing, and the postural effects of gravity. At any point in time, the management of the lower extremities will depend on the child's general development. Lower limb paralysis, hydrocephalus, bladder infections, hydromyelia, and Arnold Chiari malformation, all contribute to developmental delay. A child's potential for mobility varies with the severity of the motor and sensory deficit. Surgery is done to correct deformity, provide joint stability, and improve joint mobility. The results of surgery will be compromised if the child is not neurologically stable, or if appropriate therapy and orthotic care are not available. Muscle imbalance produces the problem of deformity and instability of the hip. Deformity must be corrected if the child is to assume an upright posture. Instability is of concern only in those children with a strong quadriceps muscle. Hip surgery for instability should be limited to one procedure, which must achieve a stable concentric reduction and balance the muscle forces about the hip. The common deformities seen at the knee are recurvatum, knee flexion contractures, and genu valgum. Most knee deformities can be corrected by soft tissue procedures. Well-designed orthoses rocker sole shoes, and appropriate gait training help prevent knee deformities. The goal in managing foot deformities is to achieve a plantigrade foot with stable skin. Whenever there is a problem with sensation, concentrated pressure in one area of a deformed foot will lead to skin breakdown. Surgical procedures must completely correct deformity and restore muscle imbalance. After surgery, meticulous orthotic care is required to prevent skin breakdown and avoid loss of correction. The orthopedist has a significant role in helping a child with spina bifida to achieve a pattern of development as near normal as possible. He or she must work in concert with a team of professionals and realize that orthopedic surgery is but an incident in the habilitative program. This rather chatty narrative is based on spina bifida care experience, in Sheffield, Toronto, and Chicago.

Adolescent↗
PubMedDate not supplied

Congenital contractural arachnodactyly (Beals syndrome).

Congenital contractural arachnodactyly (CCA, Beals syndrome) is an autosomal dominant disorder that is phenotypically similar to Marfan syndrome. CCA is characterized by arachnodactyly, dolichostenomelia, scoliosis, multiple congenital contractures and abnormalities of the external ears. We report here 28 patients with CCA, in whom a wide range of phenotypic expression is observed. These individuals usually have abnormally formed ears, limited extension of fingers and toes, arachnodactyly, clinodactyly, delay of developmental milestones and psychomotor retardation. Limited extensions of elbows, knees and hips are not constant features. With time, those affected individuals experience spontaneous improvement of their contractures but the kyphosis, unlike the joint contractures, tends to be progressive. No ocular problems were found in all patients, but congenital heart defects were detected in 32.2% of them. Atrial septal defect and ventricular septal defect are common components in our patients. Within the only one family with two multiply affected siblings there is little phenotypic variation between the patients.

Adolescent↗
PubMed1988

Prosthetic replacement of the femoral head for fracture of the femoral neck in patients who have Parkinson disease.

A retrospective study was performed of forty-nine patients (fifty fractures of the femoral neck) who had Parkinson disease and who had had an endoprosthetic replacement of the femoral head. The average age of the patients was seventy-four years (range, forty-seven to ninety-two years). All of the fractures were Garden Stage III or IV. An anterolateral surgical approach was used in twenty-five hips; a posterior approach, in twenty hips; and a transtrochanteric approach, in five hips. An adductor tenotomy was required in five patients to release an adduction contracture. Ten patients died by the sixth postoperative month. The remaining thirty-nine patients were followed for a minimum of two years (average, 7.3 years). Common postoperative complications were infection of the urinary tract (20 per cent) and pneumonia (10 per cent). There was only one dislocation. At the time of writing, nineteen (80 per cent) of the surviving patients could walk.

Aged↗
PubMed2006

Biomechanical characterization and clinical implications of artificially induced crouch walking: Differences between pure iliopsoas, pure hamstrings and combination of iliopsoas and hamstrings contractures.

The purpose of this study was to characterize biomechanically three different crouch walking patterns, artificially induced in eight neurologically intact subjects and to compare them to selected cases of pathological crouch walking. The subjects were equipped with a lightweight mechanical exoskeleton with artificial muscles that acted in parallel with hamstrings and iliopsoas muscles. They walked at a speed of approximately 1m/s along the walkway under four experimental conditions: normal walking (NW), hamstrings contracture emulation (HAM), iliopsoas contracture emulation (IPS) and emulation of both hamstrings and iliopsoas contractures (IPSHAM). Reflective markers and force platform data were collected and ankle, knee and hip-joint angles, moments and powers were calculated. HAM and IPSHAM shifted ankle-angle rotation profiles into dorsiflexion during midstance compared to IPS and NW where ankle-angle trajectories were similar. HAM, IPS and IPSHAM shifted the knee angle of rotation profiles into flexion during stance, compared to NW. IPS and IPSHAM shifted hip angle of rotation profiles toward pronounced flexion while HAM shifted hip angle of rotation profile toward extension, compared to NW. HAM and IPSHAM significantly increased ankle moment during midstance, compared to IPS and NW where ankle moment profiles were similar. All experimental conditions exhibited similar behavior in the knee-moment profiles during midstance while IPS and IPSHAM knee-moment profiles exhibited significantly higher knee-extension moment during terminal stance and pre-swing. In the hip joint all experimental conditions exhibited similar shape of hip moment profiles throughout the gait cycle. HAM and IPS kinematic and kinetic patterns were qualitatively compared to two selected clinical cases, showing considerable similarity. This implies that distinct differences in kinematics and kinetics between HAM, IPS and IPSHAM may be clinically relevant in helping determine the relative contribution of hamstrings and iliopsoas muscles contractures to particular crouch walking.

Adult↗
PubMed1975

Failures in the management of congenital hip displacement in the newborn.

Congenital hip displacement in the newborn presents in two forms: (1) Those babies in whom the capsule of the hip-joint is mechanically stretched. Spontaneous reduction and recovery is high in this group, if the babies are nursed in the prone posture with double nappies (Fig 5). (2) One in a thousand babies is born with infolding of the posterior capsule and secondary contracture of the anterior capsule. This soft tissue deformation occurs in varying degrees, but it frequently prevents spontaneous reduction. Most of these cases are missed and present as infantile congenital hip displacements, when the child is 12-18 months old. In those who are unfortunate enough to be detected and treated conservatively, in the first year of life, there is a high risk of iatrogenic bony deformation. For, as in talipes equinovarus, the bony components of the neonatal hip-joint are more susceptible to mechanical compression than the soft tissue structures.

Contracture↗
PubMed1978

[Treatment of coxa magna in Perthes disease by pelvic osteotomy (author's transl)].

In M. Perthes a progressive deformation and flattening of the epiphysis is caused by the stress in the hip. In the beginning stages a varisation osteotomie gives a sufficient reduction of the joint pressure and a modelling of the enlarged head by the acetabulum is possible. In later stages a detoriation of the head deformity with fixed adduction contracture can be caused by varisation osteotomie. Enlarging the acetabulum laterally and ventrally and medializing the hip-joint by means of a Chiari pelvic-osteotomy reduces the joint pressure so far, that a restitution of the hip joint with round and congruent joint surfaces can be expected. A lateralisation of the deformed femoral head with a secondary insufficiency of the acetabulum should also be treated by an additional pelvic osteotomy, if in the arthrography the lateral part of the head does not enter the acetabulum in abduction position. In secondary osteochondritis in hip luxation the treatment should be equal. Even an advanced secondary osteoarthritis after M. Perthes could be stopped by pelvic osteotomy over years.

Adolescent↗
PubMed1992

Leg length discrepancy in total hip arthroplasty.

After conducting a thorough literature review, we realized that no consensus exists regarding the definition of a significant postoperative inequality. Whereas some investigators quantitate the disparity, accepting as much as 2.0 cm or in some cases less, others define a significant disparity as one that promotes adverse functional effects postoperatively. This lack of a consistent definition reflects the wide disparity of opinion regarding the problem of postoperative leg length inequalities in total hip surgery. Although the literature may lack consistency, it does reflect the collective experience of many surgeons and provides valuable insight when approaching the issue of limb lengths in reconstructive surgery of the hip. We offer the following suggestions: 1. Begin with a thorough history and physical examination. Question the patient as to whether he or she actually perceives a leg length inequality. 2. Be aware of apparent leg length discrepancies in patients with hip disease. The perceived limb shortening is usually the result of a fixed adduction contracture with little true shortening. 3. Develop a consistent approach of evaluation preoperatively, intraoperatively, and postoperatively. Employ reliable and convenient clinical measures and radiographic techniques. A method of intraoperative assessment is mandatory. 4. Redundancy in the system helps to minimize error. Good preoperative planning does not supplant the need for intraoperative assessment and vice versa. 5. Address the issue of offset in preoperative planning. Anticipate its misleading effects on intraoperative evaluation. 6. Mention potential inaccuracies regarding limb length reconstruction in total hip surgery as part of a routine preoperative evaluation. Patients' expectations should be high but temporized with realism.

Anthropometry↗
PubMed1991

Juvenile hyaline fibromatosis: a report of two severe cases.

Two unrelated children with a severe form of juvenile hyaline fibromatosis are described. In addition to painful flexion contractures of all of the large joints, oral and skin lesions, and typical radiologic appearance of osteolytic defects, both girls had marked growth retardation and recurrent infections. Both children died in early infancy of overwhelming infection.

Contracture↗
PubMed1981

A clinical and histological study of Ullrich's disease (congenital atonic-sclerotic muscular dystrophy).

Clinical characteristics recognized in five cases with Ullrich's disease included muscle weakness and wasting, striking contracture of proximal (sclerotic) joints and hyperflexibility of distal (atonic) joints since an early infantile stage, and slowly progressive course. The biopsied muscles demonstrated myopathic changes including a remarkable variation in fiber size, notably proliferated endomysial connective tissue, increased myofibers with centralized nuclei and a few necrotic fibers with active phagocytosis. On histochemical examination, no specific intracytoplasmic structural abnormalities such as nemaline bodies, cores and myotubes were recognized. Although both type 1 and 2 fibers were distributed in checkerboard pattern in most muscle fascicles, type 1 fiber predominance or type 2 fiber deficiency was common in severely damaged muscles, suggesting the presence of some kind of neural influence exerting on the myopathic process as the disease progressed. Since it still remains uncertain whether this disorder belongs to the muscular dystrophies, or to other neuromuscular or mesodermal diseases, we would rather label it Ullrich's disease then Ullrich's muscular "dystrophy" until its pathogenesis becomes clear.

Adolescent↗