Clubfeet associated with congenital constriction bands of the ipsilateral lower extremity

The purpose of this study was to examine the outcome of treatment of clubfeet distal to a lower extremity constriction band. Eighteen patients with 21 clubfeet distal to a lower extremity constriction band were treated during the years 1946 to 1992. Three types of bands (I to III) were defined. Three grades of feet (A to C), based on the severity of the deformity, were recognized. After treatment, the feet were classified as good, fair, or poor. At follow-up, six of 18 feet were classified as good, six as fair, and nine as poor. These results were correlated with the type of band and the grade of the foot. A grade A foot associated with type III band had the best result.

Congenital dislocation of the hip in boys

Fifty-five boys with seventy-eight congenitally dislocated hips were treated between 1965 and 1990. The patients were divided into three groups according to the initial treatment. Group I included thirty hips (twenty-two boys) that had been treated initially with a Pavlik harness. Two hips (7 per cent) had a successful outcome, and twenty-eight (93 per cent) needed additional methods of treatment. Group II included forty-two hips (twenty-nine boys) that had been treated initially with closed reduction and immobilization in a hip-spica cast. After the closed reduction, twenty-nine hips (69 per cent) were considered stable, although fifteen (52 per cent) of them needed a secondary procedure because of residual subluxation or persistent acetabular dysplasia. Thirteen hips (31 per cent) were considered unstable after the closed reduction and subsequently had an open reduction. Group III included six hips (four boys) that had been treated initially with open reduction. Two of these hips redislocated after the open reduction, and they were reduced with an additional open reduction. A pelvic osteotomy was later performed to treat persistent acetabular dysplasia in these two hips. Two hips that had been treated with an open reduction and concomitant pelvic and femoral procedures did not need additional treatment. This study demonstrates that boys who have congenital dislocation of the hip do not always respond well to treatment and constitute a high-risk group.

Surgical treatment of dysplastic spondylolisthesis. Results after in situ fusion

STUDY DESIGN

Fourteen patients who had symptomatic dysplastic spondylolisthesis with an intact pars interarticularis underwent posterolateral spinal fusion. Patients initially had low back pain, tight hamstrings, and limited forward bending. In addition, four patients had signs of progressive cauda equina or nerve root impingement. In 10 patients (71%), preoperative degree of slippage was more than 50% (mean, 72%).

METHODS

Ten patients underwent in situ posterolateral spinal fusion, and four patients with progressive neurologic symptoms had posterior decompression followed by in situ posterolateral spinal fusion.

RESULTS

All patients had solid fusion at last follow-up. A pseudoarthrosis developed in one patient, which healed after a second operation. Roentgenographic progression of the slip after fusion was rare.

CONCLUSIONS

This study demonstrated that for dysplastic spondylolisthesis in children and adolescents, in situ posterolateral spine fusion yields satisfactory results. In addition, in the presence of progressive cauda equina or nerve root impingement, posterior decompression may be necessary.

A radiolucent spine frame: a modification of the Relton-Hall spine frame

A radiolucent spine frame for obtaining intraoperative spine radiographs while performing surgery for scoliosis has been designed at the Alfred I. duPont Institute and is described here. This frame, constructed of strong radiolucent plastic compounds, is easy to use and maintain.

Oesophageal manometry in noncardiac chest pain

Chest pain of oesophageal origin is an important differential diagnosis in patients with cardiac chest pain. A preliminary survey of 40 patients with noncardiac chest pain (NCCP) revealed oesophageal motility disorder in 47.5%; achalasia cardia being the most frequent disease (47.3%). 15.8% of these patients with motility disorder had features of progressive systemic sclerosis and another 15.8% had non specific oesophageal motility disorder (variants). Compared to barium swallow, oesophageal manometry was found to be superior in the diagnosis of oesophageal motility disorder.

Genomic fingerprints of Staphylococcus aureus of bovine origin by polymerase chain reaction-based DNA fingerprinting

Staphylococcus aureus (n = 75) isolated from mammary secretions of cows with subclinical and clinical mastitis from several geographic locations in the USA were examined using polymerase chain reaction-based DNA fingerprinting. DNA fingerprints were produced using a synthetic oligonucleotide primer (5'GTAACGCC3') to produce a distinct spectrum of amplified DNA fragments facilitating a high degree of resolution for differentiating S. aureus strains. PCR-based DNA fingerprinting grouped the 75 S. aureus isolates into 19 distinct profiles. The technique differentiated closely related strains within and between geographic locations. Findings suggest that certain types are found across geographic regions suggesting a common clonal type. Within herd data suggest heterogeneity among subclinical and clinical isolates of S. aureus strains. Compared to existing typing methods, PCR-based DNA fingerprinting is easy to perform and interpret. Use of PCR-based DNA fingerprinting may allow for a more detailed investigation of the epidemiology of S. aureus mastitis in dairy cows.

Fibular transfer for congenital absence of the tibia

Twelve patients (13 extremities) who had complete congenital absence of the tibia were treated between 1963 and 1989. Three patients (three extremities) had a knee disarticulation performed as the primary procedure because they had no quadriceps function. Nine patients (10 extremities) underwent centralization of fibula under the femoral condyles (Brown procedure). Four of these 10 extremities developed a severe flexion contracture of the knee (> 25 degrees) and underwent subsequent knee disarticulation. One patient with a short stump secondary to an ipsilateral proximal femoral focal deficiency had a femorofibular arthrodesis. Five of these 10 extremities had a satisfactory result when reviewed at an average follow-up of 18 years. The patients were evaluated in reference to gait, range of motion (ROM) of the knee, quadriceps strength, prosthetic needs, and peer group sports activities. A strong quadriceps (> grade 4) was noted in all five patients who had a satisfactory result. Flexion contracture of the knee, when < 25 degrees, did not compromise the result.

Split tibialis posterior tendon transfer and tendo-Achillis lengthening for spastic equinovarus feet

Twenty-one patients with a minimum follow-up of 2 years who underwent combined split tibialis posterior tendon transfer and tendo-Achilles lengthening for equinovarus foot deformities were evaluated. The results in 15 of 18 ambulatory patients were graded as excellent or good; patients had marked improvement of their equinovarus foot deformity in both stance and swing phases of gait and became brace-free postoperatively. All non-ambulatory patients had a plantigrade foot. The complication rate was low, and patient satisfaction with the procedure was very high. In three patients, however, the procedure failed because of technical errors. We address the causes of failure and methods to avoid these errors. Preoperative computerized gait analysis does not appear to be essential in achieving a good result.

Triple osteotomy of the innominate bone in treatment of developmental dysplasia of the hip

Ten children (11 hips) who underwent triple innominate osteotomy between the ages of 11 and 16 years for treatment of symptomatic acetabular dysplasia and who had > 10 years of follow-up since operation were reviewed to determine if satisfactory results reported in an earlier review were maintained. The mean length of follow-up was 12 years (range 10-16 years). All hips were examined roentgenographically, and functional assessment was made with the Iowa hip scoring system. Ten of the 11 hips improved roentgenographically and eight improved functionally after operation. One hip required replacement arthroplasty 16 years after triple innominate osteotomy.

Complications associated with fracture of the neck of the femur in children

We reviewed 16 children with 16 displaced fractures of the femoral neck associated with complications. One was a transepiphyseal fracture, 12 were transcervical fractures, and three were basocervical fractures. The mean age at time of fracture was 11 years 7 months (range, 4 years 6 months to 16 years), and the mean length of follow-up after fracture was 6 years 11 months (range, 2-24 years). Complications in this series were avascular necrosis (AVN) (14 patients), nonunion (seven patients), premature physeal closure (15 patients), chondrolysis (seven patients), and coxa vara (two patients). Avascular necrosis, nonunion, and chondrolysis were associated with a poor outcome. Coxa vara or premature physeal closure alone was not responsible for a poor result.

Osseous and non-osseous coalition of the middle facet of the talocalcaneal joint

Sixteen patients (eighteen feet) who had a coalition of the middle facet of the talocalcaneal joint had operative resection of the coalition because nonoperative treatment, such as casts, failed to relieve the symptoms. The patients were symptomatic for an average of one and a half years (range, four months to two years) before they were seen by us. The average age at the time of the operation was fourteen years (range, seven to nineteen years). Three feet had resection with no material interposed, six had resection with interposition of fat, and nine had resection with interposition of half of the tendon of the flexor hallucis longus muscle. The average length of follow-up was four years (range, two to eight years). The result was excellent for eight feet, good for eight feet, and fair for one foot; for one foot, the result was poor because the coalition recurred. Three types of coalition were identified on preoperative computed-tomography scans that correlated with the operative findings. Type I was an osseous bridging of the middle facet joint (five feet). Type II (cartilaginous coalition) was marked narrowing of the middle facet joint with cortical irregularity (three feet). In Type III (fibrous coalition), there was only slight narrowing of the middle facet joint (ten feet). The type of coalition did not influence the result. Fibrous coalitions were the most difficult to detect; bone scintigraphy was used to confirm the diagnosis when other tests were equivocal. We believe that symptomatic coalition of the middle facet of the talocalcaneal joint should be treated with resection when non-operative methods fail to relieve symptoms.

Transepiphyseal fractures of the neck of the femur in very young children

Five severely displaced transepiphyseal fractures of the neck of the femur in five very young children were treated nonoperatively with a spica cast. Four of these fractures healed in varus, but two with an open proximal femoral physis corrected with growth. One fracture had an 18-month delay in diagnosis and treatment, but subsequently healed after a valgus osteotomy of the proximal femur and bone grafting. There was no case of avascular necrosis. We recommend initial nonoperative treatment with hip spica cast immobilization for this type of fracture in the very young child. If correction of residual coxa vara or limb length discrepancy is indicated, it may be done later.

Epiphyseometaphyseal cupping of the distal femur with knee-flexion contracture

An 11-year-old child with a history of receiving megadoses of vitamin A as an infant, and a 4-year-old child with a history of fulminant staphylococcal septicemia with multiple joint involvement presented with recalcitrant knee-flexion contractures. Roentgenography revealed epiphyseometaphyseal cupping (ie, epiphyseal invagination) of the distal femur. Osteotomy resulted in only temporary correction. Our experience suggests that in the skeletally immature child, skin traction, physical therapy, splinting, and, in some instances, two-pin tibial traction should be the treatments of choice.

Late acetabular dysplasia following early successful Pavlik harness treatment of congenital dislocation of the hip

We present the long-term results of Pavlik harness treatment in 61 patients with 74 affected hips. At the beginning of treatment, the hips were either dislocated and reducible or dislocated and irreducible. The average age of patients at follow-up was 12 years (range, 10-16 years). At 3- and 5-year follow-up, all of the hips appeared radiographically normal. However, at latest follow-up, 17% of the hips demonstrated changes in the acetabulum (an upward tilt of the outer portion of the acetabular roof or sclerosis in this area). This study emphasizes the importance of continued follow-up until patients treated for congenital dislocation of the hip reach skeletal maturity.

Intraspinal epidermoid tumors in children: problems in recognition and imaging techniques for diagnosis

Iatrogenic intraspinal epidermoid tumors are very rare. The similarity of the clinical manifestations of the tumor with other childhood problems can pose a problem in diagnosis. In addition, because of the lag in time between the lumbar puncture and the development of a symptomatic tumor, this relationship is overlooked and can cause a delay in diagnosis, as in the present report of four children. Magnetic resonance imaging was found to be superior to myelography in defining the tumor and its relationship to other structures inside the dural sac. All patients underwent surgical excision, with subsequent resolution of symptoms.

Detection of talocalcaneal coalitions by magnification bone scintigraphy

Fibrocartilaginous talocalcaneal coalitions are very difficult to identify on plain radiography in symptomatic children and adolescents before gross ossification occurs. Computed tomography (CT) has been successful in identifying osseous and some fibro-osseous coalitions. In this series, magnification imaging of the tarsus on bone scintigraphy in the medial-lateral projection correctly identified talocalcaneal coalitions, seven of the nine bars were fibrous or fibro-osseous. Three of the fibrous lesions were equivocal or normal on conventional radiography and CT. Physiologic accumulations of activity in the growing hind foot are also presented from a control pediatric population. Magnification scintigraphy of the hind foot is offered as an adjunct to plain radiography and CT in the diagnosis of elusive nonosseous subtalar bars.