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PubMed2002

[Initial management of congenital varus equinus clubfoot by Ponseti's method].

The choice of first-line treatment for congenital varus equine clubfoot remains a controversial issue largely dependent on experience. In France, functional treatment predominates. In 1948, Ponseti proposed reducing the deformity with successive casts. Although cast treatment is a very old method, Ponseti's method is original because it is based on strict rules established from anatomic evidence. The goal is not to correct the apparent deformation, but on the contrary to impose a simultaneous supination and abduction of the foot. Once the calcaneopedal block has been derotated, percutaneous tenotomy of the Achilles tendon is performed. We relate our experience with this method and recall the precise technique used to make the casts. After the cast, derotation braces are worn at night but rehabilitation exercises are not required. We emphasize the quality of the clinical reduction achieved as well as the smaller number of patients who require surgery at walking age.

Achilles Tendon↗
PubMed2002

[Treatment of congenital clubfoot with the Ponseti method].

OBJECTIVES: This study aimed to present the author's early experience with the Ponseti technique in correcting clubfoot and to evaluate the need for aggressive surgery in the first year of life. METHODS: The study included 44 feet of 31 patients (25 boys, 6 girls; mean age 3 months; range 4 days to 8 months) with idiopathic clubfoot deformities of grade II, III, or IV. Twenty-seven feet (19 patients) had not received any treatment before. Twelve patients (17 feet) had had unsuccessful prior conservative treatment elsewhere. All patients had manipulation casting in accordance with the Ponseti technique, and percutaneous Achilles tenotomy was performed in the presence of persistent equinus. Maintenance of correction was obtained with the use of a foot abduction brace. The mean follow-up period was 18 months (range 6.5 to 40 months). RESULTS: Forty-two feet (95%, 29 patients) were treated successfully using the Ponseti method. In terms of compliance with the foot abduction brace, a significant difference was noted between patients without previous treatment and those with deformities considered resistant to prior conservative treatment. The latter manifested more compliance with brace application. CONCLUSION: Ponseti method proved efficient in correcting idiopathic congenital clubfoot deformities irrespective of initial deformity grades, provided that the details of the technique are strictly adhered to. The results also suggest the role of brace application in order to avoid relapses along with the importance of increasing patients' compliance through family education and experienced orthotists.

Braces↗
PubMed2003

[Surgical treatment of orthopedic deformities due to spasticity in the lower limb].

Orthopedic deformities in the lower limb concern all joints (hip, knee, ankle, foot) with a wide range of clinical forms. Spasticity, contracture, stiffness, laxity, neurological deficit are assessed to establish the surgical procedure. Surgical techniques are adapted to the goals that are detailed with the patient and his family: standing, transferring, walking, hygiene, devices (shoes, orthosis, canes, wheelchair). Surgical procedures can associate: lengthening of contractured muscles (tenotomy with or without sutures, fractional lengthening at the musculo-tendinous junction or desinsertion), strengthening of antagonists (passive or active tendon transfer) and correction of joint deformity (arthrolysis, arthrodesis, arthroplasty). In adults, the most common deformities are the equinus or equinovarus foot, toe curling, hip adductum, knee flessum. Talus or knee recurvatum are less frequently observed. The association of various deformities raises questions concerning the hierarchy of surgical procedure, from an anatomical point of view (do we start with proximal or distal joint first?) as from chronological concerns (shall we do one or more procedures?). Pluridisciplinary assessment using neurological anesthetic blocs and dynamic EMG or gait analysis is necessary to detail the aims of surgery and choose the surgical procedures.

Foot Deformities, Congenital↗
PubMedDate not supplied

Role of surgery in the prevention and correction of hip subluxation and dislocation in cerebral palsy.

Forty-three patients (80 hips) were available for clinical and radiological follow-up. These patients underwent adductor tenotomies separately or in combination with other procedures on the hip, with or without proximal femural correction. The range of abduction in all hips before surgery was 40 degrees or less, and in 54 hips combined with flexion-contracture (10 degrees-50 degrees).

Adolescent↗
PubMed1992

Sciatica caused by piriformis muscle syndrome: report of two cases.

The diagnosis of piriformis muscle syndrome, an unusual cause of sciatica, is difficult. However, with the advancement of imaging techniques, it has become clear that the condition is not just clinical speculation, but is a definite entity. We report on two cases with piriformis muscle syndrome, diagnosed on the basis of: a history of sciatica; physical findings, such as a tender point at the sciatic notch and around the piriformis muscle by palpation of the gluteal region, and by a digital pelvic examination; and computed tomography (CT) to demonstrate hypertrophy of the piriformis muscle. In both cases, a tenotomy of the piriformis muscle at the greater trochanter relieved entrapment of the sciatic nerve and gave satisfactory results. Since local tenderness at the piriformis muscle is the most reliable physical finding, a pelvic examination is recommended in the evaluation of suspected cases of piriformis muscle syndrome. CT is helpful in showing hypertrophy of the piriformis muscle. Detailed history taking, a careful physical examination, and versatile use of CT or magnetic resonance imaging can lead to an early, accurate diagnosis and proper treatment.

Adult↗
PubMed1992

Prognostic factors in congenital dislocation of the hip treated with closed reduction. The importance of arthrographic evaluation.

We reviewed the clinical records, arthrograms, and roentgenograms of sixty-one children who had seventy-two congenitally dislocated hips in an effort to identify factors that can be used to predict the outcome of treatment. Only patients who had been followed clinically and roentgenographically for a minimum of two years after the initial closed reduction were included in the study. The mean age at the time of closed reduction was thirteen months (range, three to forty-one months). The mean age at the time of the most recent follow-up was six years (range, two to fifteen years). The mean duration of follow-up after the initial closed reduction was five years (range, two to thirteen years). There was no statistical difference between the good, fair, and poor-result groups with regard to sex, the age at the initial reduction, the traction station, the side of involvement, the initial acetabular index, the initial grade of displacement, the effect of adductor tenotomy, and several of the arthrographic measurements. The medialization ratio (the percentage of the horizontal radius of the cartilaginous femoral head that lay medial to the Perkins line), measured at the time of the reduction, was significantly different (p < 0.04) between the hips for which the result was good or fair and those for which the result was poor. The medialization ratio averaged 75 per cent in the hips for which the result was good, 66 per cent in those for which the result was fair, and 57 per cent in those for which the result was poor. Limbus shapes 5 through 8 were associated with avascular necrosis (p < 0.05) and a poor result (p < 0.03).

Acetabulum↗
PubMed1992

Anterior capsulotomy and continuous passive motion in the treatment of post-traumatic flexion contracture of the elbow. A prospective study.

Thirty-three patients who had a post-traumatic flexion contracture of the elbow were managed consecutively with anterior capsulotomy without tenotomy of the biceps tendon or myotomy of the brachialis muscle. The first fifteen patients (Group I) did not receive continuous passive motion postoperatively. Preoperative active extension for Group I was to an average of 48 degrees short of full extension, which improved to 19 degrees at a mean follow-up time of forty-five months. Subsequently, eighteen patients (Group II) received continuous passive motion postoperatively for a mean of six weeks. Preoperative active extension for Group II was to an average of 55 degrees short of full extension, which improved to 23 degrees at a mean duration of follow-up of thirty-five months. The mean preoperative arc of motion for Group I was 69 degrees, which improved to 94 degrees postoperatively. The mean preoperative arc of motion for Group II was 48 degrees, which improved to 95 degrees postoperatively. Five patients in Group I and six patients in Group II had severe preoperative heterotopic ossification. There was no correlation, however, between preoperative heterotopic ossification and the amount that extension of the elbow improved postoperatively. There was no postoperative increase in heterotopic ossification. Four patients in Group I and six patients in Group II had severe post-traumatic osteoarthrosis preoperatively. Anterior capsulotomy is an effective treatment of post-traumatic flexion contracture of the elbow. Although the postoperative use of continuous passive motion did not significantly improve mean active extension, it did improve active flexion and the total arc of motion.

Adolescent↗
PubMed1992

[Quintus varus supraductus. Results of the surgical treatment by cutaneous graft, internal capsulotomy and external transfer of the extensor of the 5th toe].

The overlapping fifth toe has often a congenital origin. It may be isolated or associated with an another pathology, congenital or acquired, but the relationship between them. Cannot be ascertained. The overlapping fifth toe is responsible for an esthetic deficit and/or a functional discomfort, it justifies a correct surgery. Twenty-one feet in 16 patients aged from 2 to 30 years (especially between 5 and 15 years) have been operated on and reviewed after a mean follow-up of 4 years. The technic associated a cutaneous dorsal Z-plasty on the cutaneous retraction a medial and dorsal capsulotomy of the metatarso-phalangeal joint, an external transfer of the fifth extensor tendon or its tenotomy and, in 10 cases, a plantar skin resection 19 results were excellent, one fair result and one failure. The condition of a stable result seems to be based on a complete and spontaneous correction of the deformity at the end of the operation.

Adolescent↗
PubMedDate not supplied

[Our experience in the conservative surgical treatment of coxarthrosis].

The authors present the substantiation of the use of conservative treatment in a series of 163 patients with coxarthrosis operated upon between 1983 and 1990. In 135 of these patients various types of osteotomies were performed: Pauwels valgisation or varus femoral osteotomy (42 cases), McMurray displacement osteotomy (41 cases), varus and displacement osteotomy (19 cases) and Chiari pelvic osteotomy (33 cases). In the remainder of 28 patients tenotomies and hip denervations were performed. The postoperative results, estimated by a strict clinico-radiological survey revealed a marked clinical improvement and radiographically a restoration of joint congruence in about 80% of the cases.

Hip Dislocation↗
PubMed1992

The surgical treatment of tendinitis. Clinical rationale and biologic basis.

The rationale for surgical treatment of tendinitis is to induce a modulation of the tendon cell-matrix environment by either promoting a renewed wound repair cycle or by the removal of aberrant tissue. The adequacy of healing as a result of surgical tendon treatment has been poorly documented histologically; what evidence exists suggests normal tissue is not achieved. The clinical experience of the authors as well as preliminary analysis of wound healing patterns in a longitudinal internal tenotomy rabbit tendo-Achilles model are discussed.

Achilles Tendon↗
PubMedDate not supplied

Six years of experience with a new surgical algorithm in developmental dysplasia of the hip in children under 18 months of age.

One hundred thirty-seven developmentally dysplastic hips of 107 children with a mean age of 11 months were treated by the same surgical algorithm. Following iliopsoas and adductor longus tenotomies by the Ferguson posteromedial approach, the operation was ended in case of arthrographically documented concentric reduction (Tönnis grade 1 reduction) and an open reduction was performed in case of nonanatomic arthrographic reduction (Tönnis grade 2 or 3 reduction). Mean follow-up was 4.2 years. The need for open reduction increased in preoperatively dislocated hips that were proximally displaced according to the Tönnis classification. Somewhat better latest acetabular index values were seen in hips having lower preoperative dislocation grades that were surgically treated before the age of 12 months. Rates of avascular necrosis of the femoral head, redislocation, and secondary operation were 13%, 1%, and 2%, respectively. The authors concluded that although mid-term results of this new surgical algorithm in developmental dysplasia of the hip was satisfactory in infants younger than 18 months of age, long-term follow-up is needed for better understanding of its use.

Algorithms↗
PubMed1992

The boutonniere deformity.

Understanding the pathophysiology of the boutonniere deformity requires a complete understanding of the anatomy of the dorsal tendon apparatus. This unique tendon mechanism often becomes unbalanced, requiring correction of its components. Splinting is the cornerstone of treatment for the boutonniere deformity. In the acute stage, splinting ensures that the continuity of the central tendon to its insertion into the middle phalanx is maintained, and in the chronic stage, its function is to correct the flexion contracture of the PIP joint and stretch the retinacular ligaments. Splinting is also important postoperatively because it permits healing of the central tendon and lateral bands in their correct anatomic positions. Without proper splinting, the patient with the boutonniere deformity could not be successfully treated. Frequently, surgery is necessary, and the choice of procedure depends on the stage of the condition and the extent of the defect in the extensor tendon mechanism. The procedure also depends on the success of the splinting program and stretching of the tight retinacular structures. If passive joint mobility can be restored and if tendon imbalance and retinacular tightness persist, rebalancing is necessary. This rebalancing can be accomplished by a tenotomy of the terminal extensor tendon, a lysis or release of the retinacular structures, or release of the insertion of the extensor tendon at the base of the proximal phalanx. Reconstituting the defect in the central tendon over the PIP joint is accomplished by using a variety of procedures, including mobilization and advancement of the more proximal portion of the central tendon, shifting the lateral bands, or a tendon graft.

Arthritis, Rheumatoid↗
PubMed1992

Longterm followup of hip and knee soft tissue release in juvenile chronic arthritis.

Longterm results of soft tissue release for hip and knee flexion deformity in 27 patients with juvenile chronic arthritis (JCA) were evaluated. A total of 53 tenotomies were reviewed: 22 hips and 31 knees. Mean age at surgery was 12.1 years, with a mean underlying disease duration of 6.3 years and a postoperative followup of 5 years. Patients were evaluated at 3-6 months, then at one, 3 and 5 years. Results showed a marked drop in flexion contracture and an improvement in joint range up to the first 3 years postsurgery, but beyond this period benefits achieved were gradually partially lost. Only 37% of patients were able to walk before surgery. At one year followup, 81% were able to do so. Soft tissue release thus seems a beneficial therapeutic alternative to preserve both alignment and function in hip and knee flexion deformity affecting patients with JCA.

Adolescent↗
PubMed2004

[Orthopaedic problems in adults with cerebral palsy].

BACKGROUND: There is little information about the need for orthopaedic surgery in adults with cerebral palsy; we wanted to assess this problem. MATERIAL AND METHODS: The material included 37 adults with cerebral palsy (19 women and 18 men), mean age 39. The degree of physical disability was mild in 19 cases, moderate or severe in 18. The patients were assessed by clinical examination and radiographs of hips and spine. RESULTS: 15 patients had pain located to the spine or lower extremities but no-one had severe or invalidating pain. Subjects with moderate or severe disability had a markedly reduced range of motion in the hip and knee joints. Subluxation or dislocation of the hip joints was found in six patients but only one of them had hip pain. Orthopaedic surgery had been performed in 23 patients. In 8 patients we found indications for additional orthopaedic surgery aimed at relieving pain, reducing contractures or improving function. The most frequent procedures would be tenotomies in the hip and knee regions, heel cord lengthening, and triple arthrodesis of the foot. INTERPRETATION: Regular follow-up of adults with cerebral palsy is recommended in order to reveal musculoskeletal problems that can be improved by orthopaedic surgery.

Adult↗
PubMedDate not supplied

[Results of late synovectomy of the hip in juvenile chronic arthritis].

The aim of this study was to examine the indication for total synovectomy of the hip in juvenile chronic arthritis. For this purpose, five children with six treated hips were followed up. At the time of synovectomy all patients were suffering from therapy resistance and progressive destructive coxitis, as a result of juvenile chronic arthritis. The procedure carried out must, consequently, be regarded as late synovectomy. At the time of the follow-up examination--at least 2 years after the operation--all patients had lasting relief from pain. The range of hip movement could not be improved, despite being accompanied by tenotomies and consistent rehabilitation in the postoperative years. The functional capacity in everyday life also failed to improve. During the post-operative radiographic follow-up the deterioration of the hips proceeded more rapidly than expected for this spontaneous course of treatment. The results lead to the conclusion that the relief of pain due to a late synovectomy of the hip is achieved at the expense of a rapidly progressive destruction of the joints. For this reason, the late synovectomy of the hip in juvenile chronic arthritis should be regarded as the last possibility where resistance to conservative therapy exists.

Activities of Daily Living↗
PubMed2003

[The surgical results of correcting strabismus with inferior oblique hyperfunction].

PURPOSE: To evaluate the surgical results of correcting strabismus with inferior oblique hyperfunction. MATERIAL AND METHODS: A retrospective chart review of 40 patients, who underwent surgery from 1999-2001 was performed. 7 patients had isolated inferior oblique hyperfunction, 5 with hypertropia, 23 patients had esotropia with inferior oblique hyperfunction and 5 patients had exotropia with inferior oblique hyperfunction. The recession of inferior oblique muscle was undergone in cases with inferior oblique hyperfunction, sometimes in hypertropia with anteposito. The recession-resection of rectus muscles with myotomy-tenotomy of inferior oblique muscle or his recession usually were performed in cases with coexisting esotropia or exotropia. RESULTS: In all cases eyes were acceptably aligned. The recession of inferior oblique muscle is the most effective method of operation in high oblique hyperfunction.

Child↗
PubMed1992

Surgical correction of foot deformities after stroke.

Of 104 patients with corrective surgery for foot deformities subsequent to a cerebrovascular accident from 1980 until 1983, 53 patients returned for clinical examination and 22 patients were evaluated by questionnaire and telephone interview. The average follow-up period was 6.4 years. The operative techniques were tenotomy of the toe flexors for hammer-toe deformity, lengthening of the aponeurosis of the gastrocnemius for equinus deformity, and transfer of the anterior tibial tendon or the posterior tibial tendon or the long toe flexors for varus deformity. In 74% of patients, correction was maintained; 79% did not use an orthosis; 51% could bathe unassisted; and 76% were satisfied with the results. The ability to walk was related to the degree of paralysis, the age of the patient at surgery, and the walking speed at discharge.

Cerebrovascular Disorders↗
PubMed2004

[Anesthetic management of a child with Schwartz-Jampel syndrome].

A 6-year-old child with Schwartz-Jampel syndrome (SJS) underwent tenotomy of bilateral lower limbs under general anesthesia. Patient with SJS has problems such as difficulty of intubation owing to microstomia and jaw muscle rigidity, and is susceptible to malignant hyperthermia by using volatile inhalation anesthetics. In this case, we used a laryngeal mask for airway management and anesthesia was maintained with inhalation of nitrous oxide and continuous i.v. infusion of propofol with caudal block, and his clinical course was uneventful.

Anesthesia, General↗