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This prospective study of the treatment of Dupuytren's Contracture in 78 hands has been designed to investigate the role of subcutaneous fasciotomy. The results suggest that in hands where the contracture is predominantly at the metacarpophalangeal joint, then percutaneous fasciotomy is of value.
A girl with knee flexion contracture secondary to linear scleroderma with hemiatrophy was treated with hot packs, gentle stretching and a serial posterior splint. The knee range of motion gained 35 degree over a period of 16 weeks. Nine months, later knee contracture had regressed. As an alternative method of treatment, continuous stretch was applied by using a front extension splint together with transcutaneous electrical nerve stimulation. The knee range of motion gained 55 degrees over a period of 6 weeks.
A 7-year-old boy with Schwartz-Jampel syndrome was evaluated for a mobility and seating device. Assessment results indicated reduced upper and lower extremity function due to tight stiff muscles, labored and slow movements, hip extension contractures, asthmatic and restrictive pulmonary disease, and normal intelligence. Due to the combination of severe musculoskeletal and pulmonary disease, he had not been able to attend school or interact normally with his environment. Ambulation for more than a few feet was precluded by reduced pulmonary capacity and stiff, slow muscle movements which did not improve with medication. Because of hip extension contractures, he could not sit upright in a chair. An Amigo electric cart with a modified straddle seat enabled the patient to sit upright, attend school, and explore his environment with greater mobility. The unit is simple to operate, adaptable, and cost effective.
Eighteen children with unilateral dysplasia of the hip were found to have asymmetrical gluteal folds and an apparent limb-length inequality secondary to pelvic obliquity caused by an abduction contracture of the contralateral hip. The dysplastic hip was on the left in all but one patient. As a result of the pelvic obliquity, the femoral head on the high side of the pelvis was directed superolaterally, stretching the relaxed capsule still farther. The femoral head was then not concentrically reduced, and the pressure it caused on the superior border of the labrum contributed to the development of the acetabular dysplasia. The eighteen dysplastic hips were treated with abduction splinting and stretching exercises of the contralateral hip to decrease the abduction contracture. All of the dysplastic hips returned to a normal roentgenographic appearance with this treatment. Acetabular dysplasia without dislocation of the hip is not always appreciated by clinical examination, but the asymmetry of the gluteal folds and the apparent limb-length inequality that were seen in all of the children in this series were obvious clinical signs. These findings must be differentiated from the anterior thigh-fold asymmetry that is frequently seen without underlying pathology.
We studied the extensibility of the quadriceps muscle and the hamstring muscles in 822 healthy male adults. 1) Extensibility of the quadriceps muscle The average angle of the buttock elevation phenomenon (B.E.P.) was 124.0 degrees +/- 16.71 on the right leg and 122.2 degrees +/- 19.75 on the left leg. And the contracture of the quadriceps (B.E.P. less than or equal to 100 degrees) was found in 16.1% of them. 2) Extensibility of the hamstring muscles The average angle of the straight leg raising test (S.L.R.) was 79.3 degrees +/- 9.56 on the right leg and 79.9 degrees +/- 9.56 on the left leg. And the contracture of the hamstrings (S.L.R. less than 70 degrees) was found in 10.3% of them.
A significant abduction contracture of the hip followed closed reduction and pinning of an acute slip of the proximal femoral epiphysis in a 13-year-old boy. The contracture was corrected by removal of this bony prominence. Over-reduction of the slipped epiphysis into valgus is thought to have stimulated bony overgrowth at the posteromedial aspect of the capital femoral epiphyseal-neck junction. This causes a block to adduction by abutting against the inferior lip of the acetabulum. To our knowledge, this complication has not been previously reported.
The continuous extension of Dupuytren's contracture prior to aponeurectomy in severe cases, introduced by Messina, is presented. This technique demonstrates the possibility of reversing contractures; it simplifies the surgical treatment thereafter and avoids difficulties in blood circulation and sensibility. First results in ten patients are presented.
Twenty-eight children were treated who had limited flexion of the hips and various degrees of contracture of the abductor and external rotator muscles because of fibrosis of the gluteus maximus muscle. Although the lesions could be classified as those associated with poliomyelitis, infection of the gluteus maximus muscle, and fibrosis of unknown etiology, all forty-five hips had a typical restriction of motion such that an affected hip could not be flexed in the usual sagittal plane, but had to be flexed in abduction. Poliomyelitis may have been adjunctive to the causative factor of the lesion in some cases but the probable primary etiology was multiple intramuscular injections. Excellent correction of the hip contracture was achieved in all patients by division of the fibrotic bands.
In a retrospective study, 60 shoulders in 38 adults with deltoid contracture were surgically treated by proximal or distal releases. Twenty-three patients, representing 34 treated shoulders, were followed up for at least 2 years (median was 4 years). By the last follow-up, all patients achieved satisfactory outcomes: freedom from pain, full range of motion, and normal muscle power. The proximal release was used in patients with one-portion (one of the deltoid origins) involvement, and the distal release was used in patients with two- or three-portion involvement. Three shoulders (5%) had postoperative complications in the form of intramuscular hematomas, which were resorbed spontaneously within 3 weeks. The authors recommend surgical release to treat deltoid contracture whenever indicated.
Five pediatric patients who presented with hip contractures are described. There were 3 boys and 2 girls ranging in age from 7 to 14. None had morning stiffness and one complained of no pain at all. Each had undergone several diagnostic procedures and had seen an average of 2.5 doctors before receiving the diagnosis of arthritis. All were antinuclear antibody negative and HLA-B27 positive, and they had excellent responses to treatment with nonsteroidals and physical therapy. HLA-B27 positive arthritis should be considered in the differential diagnosis of otherwise unexplained hip contractures in children.
This case of Dupuytren's contracture was seen in a 65-year-old Taiwanese male farmer patient. The patient complained of a progressive inability to fully extend the ring and middle fingers of his dominant hand over the last three years. Clinically, a longitudinal cord-like mass surrounded the distal palmar crease of the hand and digital flexion contraction of the ring finger was more affected than the middle finger. Histopathologically, the excised tissue was of a mixed, moderate and scantily cellular type. After surgical treatment by limited fasciectomy, the patient's hand recovered fully. No recurrent contracture was noted after three years of follow-up.
Golden retriever muscular dystrophy (GRMD) is an X-linked myopathy homologous with Duchenne muscular dystrophy of human beings. Affected dogs have progressive clinical dysfunction due to muscle wasting and contractures. Deficits progress particularly rapidly between 3 and 6 months of age. To better characterize the role of contractures in this deterioration, the flexor surface, nonweight-bearing tarsal joint angle was measured in GRMD-affected dogs and clinically normal littermates at both ages. The mean +/- SD tarsal joint angle for clinically normal dogs decreased from 164.6 +/- 6.09 degrees to 145.6 +/- 8.80 degrees between 3 and 6 months (P < 0.0005). The value for GRMD-affected dogs decreased from 153.3 +/- 11.44 degrees to 117.6 +/- 24.55 degrees (P < 0.005). The angle for clinically normal dogs was greater than that for GRMD-affected dogs at both ages (P < 0.05 at 3 months and P < 0.01 at 6 months). The decrease in tarsal joint angle, at times to less than 90 degrees, correlated well with other phenotypic features of GRMD, such as loss of the ability to walk.
We reviewed retrospectively 94 patients who had undergone soft-tissue release to correct flexion contracture of the knee to determine the incidence of postoperative hypertension. The cause of contracture in most patients was cerebral palsy (45) or old poliomyelitis (39). Twenty patients developed persistent hypertension. Two of them were symptomatic, one developing hypertensive encephalopathy. Patients who had had poliomyelitis were at a higher risk than those with cerebral palsy; the risk increased with bilateral procedures. The amount of correction achieved had no influence on the incidence of hypertension.
Ten patients (14 knees) with severe knee flexion contractures were treated by gradual mechanical distraction using either the Ilizarov or Orthofix external fixator. Range of motion improved from an average flexion contracture of 60 degrees before surgery to 16 degrees at the follow-up evaluation. Range of motion results were graded good or excellent in five knees, fair in two knees, and poor in three knees. Average total arc of motion remained essentially unchanged when comparing the preoperative (59 degrees) with the follow-up results (63 degrees). However, the functional position of this arc improved significantly. Problems encountered included a "rebound" phenomena after frame removal, with loss of the temporarily increased total arc of motion. The role of hamstring tenotomy and radical posterior knee release remains unclear.
Two previous case reports have described an apparently new lethal syndrome consisting of pachygyria, joint contractures and facial abnormalities (Winter et al., 1989; Tsukahara et al., 1990). Another report describes a non-lethal case in which dysmorphic features were not noted (Massa et al., 1988). We now report on what appears to be an additional lethal case. This male infant had a lethal condition with features of large fontanelle, pachygyria with incomplete opercularization, varus contractures of the hands and feet, small palpebral fissures, hypertelorism, a small penis, cryptorchidism, camptodactyly and a sandal gap deformity. These cases appear to represent a new lethal lissencephaly syndrome associated with arthrogryposis and facial dysmorphism, which we propose to call the Winter-Tsukahara syndrome.
In the early stage of the disease a group of patients was treated with radiotherapy, later another group with injections of superoxid-dismutase. The results of follow-up examinations 7 years after radiotherapy and 3 years after treatment with superoxid-dismutase respectively do not differ clearly from spontaneous course of Dupuytren's contracture grade one. At present we cannot recommend an alternative treatment for early stage Dupuytren's contracture.
Profound hypothermic circulatory arrest is frequently used to facilitate the surgical repair of congenital heart defects in neonates. Deep hypothermia is achieved by a period of core systemic cooling during cardiopulmonary bypass before cardioplegic arrest. There have been conflicting reports with respect to the consequence of perfusing a nonarrested newborn heart under hypothermic conditions. This in vitro study was designed to prolong the clinically simulated hypothermic perfusion sequence into an extreme condition and to test the hypothesis that prolonged cold perfusion of the nonarrested newborn myocardium could, in fact, be detrimental. Twenty-four newborn piglets (5 to 7 days old) were randomly assigned to four groups and studied in a crystalloid perfused Langendorff heart model. The first two groups of hearts (n = 6 per group) were subjected to either 30 minutes (group I) or 90 minutes (group II) of cold perfusion at 15 degrees C, followed by 90 minutes of ischemia and then 30 minutes of normothermic reperfusion. In a second experiment, group III hearts subjected to 30 minutes of cold perfusion were compared with group IV (90 minutes of cold perfusion) without ischemic insult in either case. Postischemic recovery of isovolumetric developed pressure was significantly impaired in group II (16.1% +/- 7.4% [II] versus 65.5% +/- 4.8% [I], p < 0.05), and 50% of the hearts had no spontaneous cardiac activity on reperfusion. End-diastolic pressure showed significant contracture with prolonged cold perfusion: group II 57.3 +/- 13.9 mm Hg versus group I 14.8 +/- 1.8 mm Hg, p < 0.05. In the absence of ischemia, a similar relationship was observed between groups IV and III (left ventricular developed pressure 68.5% +/- 3.6% versus 82.4% +/- 4.2%, p < 0.05, and left ventricular end-diastolic pressure 23.5 +/- 6.2 mm Hg versus 13.3 +/- 2.6 mm Hg, p = not significant. Ultrastructural examination revealed severe damage to the myocardial cells and contraction band necrosis in group II (prolonged cooling and ischemia). These results suggest that prolonged cold perfusion of the nonarrested newborn heart impairs functional recovery and is therefore detrimental. When followed by a period of ischemic arrest, it further potentiates the myocardial injury and induces severe contracture. This preceding adverse effect of prolonged myocardial cold perfusion before cardiac arrest may, in part, explain the suboptimal protective effect of cardioplegia in neonates.
Recent media attention has transformed breast augmentation, a routine surgical procedure, into a highly controversial one. Capsular contracture is cited in both the lay press and scientific literature as the most frequent complication of breast augmentation. This retrospective study compares two similar groups of breast augmentation patients. The first group consists of 98 consecutive patients utilizing smooth-surface silicone implants, and the second group consists of 99 consecutive augmentations using textured-surface silicone implants. The operative technique and postoperative care were identical--with the surface differences being the only significant variable. Textured-surface silicone implants are shown statistically to reduce capsular contracture to 4 percent, compared with a 21 percent incidence with smooth-surface silicone implants.