Late knee problems in myelomeningocele

This study was undertaken to assess the incidence and etiology of knee problems in a long-term follow-up of myelomeningocele patients. Of the 72 community ambulators reviewed, 17 (24%) had significant knee symptoms. A specific gait pattern was identified in symptomatic patients with low lumbar lesions, which may be explained on the basis of hip abductor and calf muscle weakness. These patients have a characteristic gait, which places abnormal stress on the knee, leading to medial and anteromedial rotary instability and eventual degenerative change. It is likely that disability resulting from knee symptoms will be the factor precluding independent ambulation in the patients reviewed in this study.

The natural history of hip deformity in myelomeningocele

We studied 1061 children with myelomeningocele, reviewing 3184 pelvic radiographs from 802 patients. Hip dislocation had occurred by the age of 11 years in 28% of children with a thoracic neurosegmental level, 30% of those with an L1/2 level, 36% of L3, 22% of L4, 7% of L5 and only 1% of those with sacral levels. Hip dislocation was not inevitable even when there was maximal muscle imbalance about the hip. The average hip flexion contracture in children aged 9 to 11 years was significantly greater in those with thoracic (22 degrees) and L1/2 (33 degrees) levels than in those with L4 (9 degrees), L5 (5 degrees) or sacral (4 degrees) levels. Our findings indicate that muscle imbalance is not a significant factor in the production of flexion deformity or dislocation of the hip; both are commonly seen in the absence of imbalance. The restoration of muscle balance should no longer be considered to be the principal aim of the management of the hip in children with myelomeningocele.

The management of tibial torsion in patients with spina bifida

We reviewed 20 patients with spina bifida who had had surgical management of tibial torsion. Eight had had bilateral procedures and 12 a unilateral procedure, giving a total of 28 limbs for analysis. We performed closed osteoclasis on seven limbs and tibial osteotomy on 21. In the closed osteoclasis group six limbs (85%) had a good result after an average follow-up of nine years (2 to 22). All limbs developed postoperative anteromedial bowing of the tibia which later remodelled. In the tibial osteotomy group 19 (90%) had a good result. The average follow-up was nine years (2 to 28). Complications occurred in seven limbs (33%). We recommend closed osteoclasis of the tibia for the young patient with spina bifida in whom walking is impeded by excessive internal tibial torsion, and supramalleolar tibial osteotomy in the older patient with excessive external tibial torsion and a planovalgus foot.

Range of knee motion in normal neonates

Fifty-seven normal neonates were examined at birth and at 3 and 6 months (to within 7 days). Range of knee motion and of hip flexion contracture were measured. Mean knee flexion contracture was 21.4 degrees at birth, reducing to 10.7 degrees at 3 months and 3.3 degrees at 6 months. Decreasing range of knee flexion was noted in the same period. The natural history of normal knee motion is important in interpreting findings in patients with neuromuscular disorders.

Use of the Pavlik harness for hip displacements. When to abandon treatment

Seven hundred twenty congenitally dislocated or subluxated hips in 550 patients less than one year old, treated with the Pavlik harness, were retrospectively reviewed. Overall, 11% of the hips proved irreducible by Pavlik harness treatment, 9% had dysplasia at the end of harness treatment, and 5% developed dysplasia by the age of two years two months (average). Fourteen percent of the hips positive for Ortolani's sign, 6% of the hips positive for Barlow's sign, and 2% of the congenitally subluxated hips required open or closed reduction followed by plaster hip spica immobilization. Avascular necrosis occurred in 0.7% of the hips treated with the Pavlik harness alone. Transient irritability with pain and limited motion of the hip occurred in 1% of the hips. The Pavlik harness is not appropriate for the larger child, most children older than eight months of age, the child in whom the examiner does not get an adequate sense of reduction, the hip that redislocates with the slightest adduction, and the hip that requires excessive flexion to maintain reduction. Pavlik harness treatment should be abandoned in favor of other methods if, after two to four weeks of use, abduction has not improved sufficiently to allow reduction, the hip has not reduced, or the hip remains unstable.

Benign paroxysmal torticollis of infancy

Benign paroxysmal torticollis is a self-limiting condition occurring during infancy. It resolves by the age of two to three years. Periodic episodes of torticollis may randomly alternate from side to side and be associated with other symptoms. The aetiology is unknown and no treatment is effective. It is relatively uncommon, and has not been previously reported in the orthopaedic literature, although initial referral may well be to an orthopaedic surgeon. We report four cases, and review the literature.

Lower extremity alignment in children with spina bifida

Our purpose was to describe the natural history of lower extremity alignment in spina bifida patients. We prospectively evaluated all spina bifida patients seen at the Children's Hospital in Seattle since 1971 and at the Royal Children's Hospital in Melbourne since 1979. Serial examinations were performed on 434 patients, ranging from birth to 23 years of age. The lower limbs of children with spina bifida had neutral alignment at birth that gradually increased to 6 degrees of valgus--a pattern different from normal children. Valgus greater than 10 degrees was observed in only 6% of patients, and the degree of angular deformity was not affected by walking, the use of an above-knee orthosis, or neurosegmental level. An above-knee orthosis to prevent malalignment does not appear to be warranted and continued ambulation does not significantly contribute to lower extremity deformity.

Vertical subluxation of the patella: an unusual feature of multiple epiphyseal dysplasia

Abnormally shaped, usually double-layered, patellae are recognized as occurring in multiple epiphyseal dysplasia. The case described is unusual in that an associated defect appeared in the femur and resulted in mechanical symptoms.

Natural history of knee contractures in myelomeningocele

The natural history of knee contracture was determined in a prospective study of 850 myelomeningocele (MM) patients, ranging in age from neonate to 23 years, excluding patients after knee surgery. Fixed flexion contracture of 10 degrees at birth decreased by age 9 months but increased thereafter if the patient's MM level was higher than L3. In the thoracic/L1-L3 level patients, the mean fixed flexion contracture was 18 degrees with and 17 degrees without knee flexor spasticity. Range of knee flexion remained at 126 degrees until age 3 years, and decreased thereafter if the patient's MM was higher that L3. This study demonstrates that muscle imbalance and spasticity play a minimal role in development of knee contracture.

Modifications to the traditional description of neurosegmental innervation in myelomeningocele

The consistency between patterns of lower-limb muscle strengths in children with myelomeningocele and Sharrard's classic description of segmental innervation was examined in 291 patients. Although it has been assumed that medial hamstring innervation was from a similar neurosegmental level as gluteus medius, and gluteus maximus was from a similar level as gastrocnemius-soleus, the authors found that medial hamstring strength more frequently correlated with iliopsoas and quadriceps, and glutei with anterior tibialis. It is proposed that children with myelomeningocele be grouped according to specific muscle strength rather than by neurosegmental level.

Bilateral hypoplastic calcanei

A previously undescribed anomaly of the calcaneus occurred in an otherwise healthy 2-month-old girl. There was marked bilateral hypoplasia of the calcanei, involving approximately the posterior half of each. The child stood at 15 months and walked at 22 months. At age 5 years, the child had a slight in-toed gait that corrected with dorsiflexion. Her only problem has been some difficulty with shoeware. The etiology of this anomaly remains conjectural.

Association of slipped upper femoral epiphysis and peroneal spastic flatfoot

A significant association between slipped upper femoral epiphysis (SCFE) and subtalar arthritis causes peroneal spastic flatfoot. Three patients with this association were observed in 136 cases of SCFE, an incidence of 2.3%; the anticipated incidence would be 0.4%. We postulate that both conditions reflect an underlying immunologic disorder.

Osteochondritis of the first metatarsal epiphysis

Two cases of painful osteochondritis of the basal epiphysis of the first metatarsal are described. Complete resolution without deformity was achieved in both patients. We suggest that this condition be considered in the differential diagnosis of transitory foot pain in childhood.

Avascular necrosis following closed reduction of congenital dislocation of the hip. Review of influencing factors and long-term follow-up

We studied the pathogenesis, incidence and consequences of avascular necrosis in 184 children treated for congenital dislocation of the hip. Of 210 hips, 99 (47%) had some evidence of avascular necrosis (total 81, partial 18). The incidence was not influenced by the age at reduction, the duration of traction or the use of adductor tenotomy. Patients treated by closed reduction without preliminary traction did not have a higher incidence of avascular necrosis. At long-term clinical and radiological review of 81 hips, early avascular necrosis significantly increased the chance of a poor outcome but did not predispose to acetabular dysplasia. If review includes minor forms of avascular necrosis, then this condition is common after closed reduction. Its presence is an important determinant of long-term radiological and clinical outcome.

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.

Avascular necrosis after open reduction for congenital dislocation of the hip: analysis of causative factors and natural history

We analysed the causative factors and natural history of avascular necrosis (AVN) after open reduction of 87 dislocated hips. AVN was observed in 37% of the hips, yet open reduction did not appear to contribute to the development of AVN and its prevalence was similar in hips treated by open or closed reduction in our institution. Only 45% of hips with AVN had a good late result. More containment procedures were required if AVN had occurred. Premature physeal closure was one late manifestation of this complication, which occurred following apparent partial AVN changes.

Torticollis due to a combination of sternomastoid contracture and congenital vertebral anomalies

We report four children with sternomastoid contracture combined with torticolis secondary to congenital vertebral anomalies. Two had features of Klippel-Feil syndrome and a proximal release of the contracted sternomastoid produced good cosmetic correction initially. Progression of the deformity occurred subsequently without recurrence of sternomastoid contracture. One child had such mild deformity that it was merely observed. The fourth child was born with torticollis without sternomastoid tightness and a vertebral anomaly was later recognised. He slowly developed a sternomastoid contracture and his condition was considerably improved by sternomastoid release. This combination of causes of torticollis has not, as far as we know, been previously reported. The clinician should be aware of it and should also realise that radiographs of the very immature spine may not disclose the bony anomalies.

Hallux varus

We reviewed 12 patients with congenital hallux varus who had had operations on 20 feet to enable them to wear normal shoes and to improve the appearance. After an average follow-up of 12.7 years the results of soft tissue procedures were satisfactory in 12 of 17 feet. Arthrodesis of the first metatarsophalangeal joint, performed primarily in one foot and secondarily in two others was also satisfactory, but metatarsal osteotomy in two feet gave unsatisfactory results leading to local amputation. The unsatisfactory results were generally due to the appearance of shortness of the first metatarsal and rarely because of symptoms or recurrent deformity.

Operation for calcaneus deformity after surgery for club foot

We describe three patients who developed gross calcaneus deformity following surgery for talipes equinovarus. One also had an associated valgus deformity and another had supination of the forefoot; all had intractable problems with footwear. Operation for transfer of the tibialis anterior to the heel, with correction of the associated deformities, was successful and improved both their gait and the shoe problems.

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.

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.