Fate of the psoas muscle after open reduction for developmental dislocation of the hip (DDH)

Avascular Necrosis of the Hip Compromises Gait Balance Control in Female Juveniles With Unilateral Developmental Dysplasia Treated in Toddlerhood

Avascular necrosis of the hip (AVN) is one of the most severe complications of surgical reduction when treating developmental dysplasia of the hip (DDH). The current study identified the differences in the balance control during walking in terms of the inclination angle (IA) of the center of pressure (COP) to the center of mass (COM), and the rate of change of IA (RCIA) between female juveniles with and without secondary AVN at the hip who were treated for unilateral DDH during toddlerhood as compared to their healthy peers. When compared to female healthy controls, the non-AVN group showed bilaterally similar compromised balance control with significantly decreased IA (p < 0.05) but increased RCIA (p < 0.04) in the sagittal plane during single-limb support (SLS) of the unaffected side, and in the frontal plane during terminal double-limb support (DLS) of the affected side. In contrast, the AVN increased between-side differences in the sagittal IA (p = 0.01), and sagittal and frontal RCIA during DLS (p < 0.04), leading to bilaterally asymmetrical balance control. Secondary AVN significantly reduced IA and RCIA in the sagittal plane (p < 0.05), and reduced range of RCIA in the frontal plane during initial DLS (p < 0.05). The trend reversed during terminal DLS, indicating a conservative COM-COP control in the sagittal plane and a compromised control in the frontal plane during body weight acceptance, with a compromised COM-COP control in the frontal plane during weight release. The current results suggest that increased between-side differences in the sagittal IA, and sagittal and frontal RCIA during DLS are a sign of AVN secondary to treated unilateral DDH in female juveniles, and should be monitored regularly for early identification of the disease.

Bilateral Asymmetry in Balance Control During Gait in Children with Treated Unilateral Developmental Dysplasia of the Hip

INTRODUCTION

About 1% of the newborn population has developmental dysplasia of the hip (DDH), altering joint biomechanics, gait performance and balance control. Pemberton's osteotomy is used in early treatment but it remains unclear whether it will help the patient regain normal balance control during gait. The current study aimed to identify the changes of the whole-body balance control during level walking in children treated for unilateral DDH during toddlerhood, in terms of inclination angles (IA) of the line joining the body's center of mass (COM) and center of pressure (COP), and the rate of change of IA (RCIA).

MATERIALS AND METHODS

Twelve girls (DDH group; age: 7.1 ± 2.1 years) who had been treated with Pemberton's osteotomy for unilateral DDH during toddlerhood and twelve healthy controls (Control group; age: 7.6 ± 2.1 years) walked at their preferred walking speed while IA, RCIA and temporal-spatial parameters were calculated from measured kinematic and forceplate data, and were compared using independent t-tests.

RESULTS

Compared to the Control group, the DDH group showed significantly decreased sagittal IA (p = 0.042) but increased range of sagittal RCIA during SLS on the unaffected side (p = 0.006), and increased peak sagittal RCIA during DLS (p < 0.008). In the frontal plane, the altered COM-COP control occurred mainly during stance phase of the affected side, showing a decreased range of RCIA during SLS (p = 0.033) followed by decreased IA (p = 0.045) with an increased peak value of RCIA (p = 0.023) during terminal DLS.

CONCLUSIONS

The children with treated unilateral DDH showed compromised, bilaterally different balance control strategies with altered COM-COP control during gait, not only during stance in the frontal plane as expected, but even more so during swing in the sagittal plane. It is thus suggested that routine assessment of the morphological changes and/or altered balance control of both the unaffected and affected hips is equally important for early identification of any signs of insidious hip problems, deteriorating balance control or increased risk of loss of balance.

The Fate of Iliopsoas Muscle in the Long-term Follow-up After Open Reduction of Developmental Dysplasia of the Hip by Medial Approach. Part 1: MRI Evaluation

BACKGROUND

There has been little information about the long-term status of the iliopsoas, which is the main flexor of the hip, after iliopsoas tenotomy in the treatment of developmental dysplasia of the hip (DDH). The aim of this study was to assess the status of the iliopsoas muscle and other flexors and extensors of the hip in long-term follow-up with magnetic resonance imaging after complete iliopsoas tenotomy in patients with unilateral DDH treated with open reduction with a medial approach.

METHODS

The study included 20 patients who underwent open reduction with a medial approach for unilateral DDH and had long-term follow-up. Magnetic resonance imaging assessment of iliopsoas, rectus femoris, tensor fasia lata, sartorius, and gluteus maximus muscles was applied and the muscles of the hip that was operated on were compared with the unoperated hip. In addition, the iliopsoas muscle was examined for reattachment and the effect of reattachment was evaluated.

RESULTS

The mean age at the time of operation was 10.53±3.61 months (range, 5 to 18 mo), and mean follow-up was 16.65±2.16 years (range, 13 to 20 y). Spontaneous reattachment of the iliopsoas was observed in 18 patients (90%), either in the lesser trochanter (65%) or the superior part of it (25%). There was no significant difference between the hips that were operated on and those that were not with regard to the mean cross-sectional areas (CSA) of the tensor fascia lata, rectus femoris, sartorius, and gluteus maximus muscles. The CSA of the tensor fascia lata, rectus femoris, sartorius, and gluteus maximus muscles showed no significant difference (P>0.05); however, CSA of iliopsoas muscle was significantly reduced in the operated hip (P<0.001).

CONCLUSIONS

Although the iliopsoas tendon was atrophied after complete iliopsoas tenotomy, it was reattached in 90% of the patients spontaneously in long-term follow-up. There was no statistically significant compensatory hypertrophy in any muscles in response to iliopsoas atrophy.

LEVEL OF EVIDENCE

Level IV-Therapeutic.

The Fate of the Iliopsoas Muscle in Long-term Follow-up After Open Reduction With a Medial Approach in Developmental Dysplasia of the Hip. Part 2: Isokinetic Muscle Strength Evaluation

BACKGROUND

The impact on long-term weakness of hip flexion of complete iliopsoas tenotomy during open reduction of developmental hip dysplasia with a medial approach has not yet been fully clarified. The purpose of this study was to investigate the isokinetic muscle strength (IMS) of hip flexor and extensor muscles in these patients and also to analyze the effect of spontaneous reattachment of the iliopsoas muscle on IMS measurements.

METHODS

The study included 20 patients. Earlier magnetic resonance imaging examination of all the patients revealed spontaneous reattachment of the iliopsoas in 18 (90%) patients. IMS measurements were performed at 60 and 150 degrees/s. The peak torque, total work (TW), average power (AP), work fatigue, and agonist to antagonist muscle ratio of the operated and nonoperated hips were recorded separately for flexors and extensors. The effect of iliopsoas reattachment on IMS was also evaluated.

RESULTS

The mean follow-up period was 16.65±2.16 (13 to 20) years. Total work (P=0.013) and average power (P=0.009) of the flexor muscles and work fatigue of the extensor muscles (P=0.030) of the operated hip were significantly decreased when compared with the nonoperated hips at 150 degrees/s. There was no significant difference between the flexor muscles of the operated and nonoperated hips (P<0.05) at 60 degrees/s and extensor muscles (P<0.05) at 150 degrees/s. In addition, patients without reattachment had lower IMS in the operated hips.

DISCUSSION

Flexor muscle strength was decreased in the operated hip against low resistance in long-term follow-up after iliopsoas tenotomy. This may reflect that hip muscle strength was decreased after prolonged activities such as sports. However, in forceful activities flexor muscle strength was retained due to iliopsoas reattachment. On the basis of this study we thought that spontaneous reattachment of the iliopsoas tendon substantially preserves muscle strength. Nonetheless possible efforts should be made to surgically reattach the psoas tendon to preserve strength of the muscle.

LEVEL OF EVIDENCE

Therapeutic level IV.

Pedobarographic Analysis Following Pemberton's Pericapsular Osteotomy for Unilateral Developmental Dysplasia of the Hip: An Observational Study

Successful clinical and radiographic outcomes have been reported in patients with unilateral developmental dysplasia of the hip (DDH) following Pemberton pericapsular osteotomy (PPO). However, residual gait deviations are seen in both the affected and unaffected limbs. To date it is not known whether these deviations result in abnormal plantar pressure in such patients. This study investigated this possibility by performing pedobarographic, clinical, and radiographic examinations after PPO in 20 patients (age: 102.5 ± 19.0 months) with unilateral DDH who underwent PPO at 34.2 ± 9.8 months of age. Plantar pressure was evaluated using the Footscan pressure plate (RsScan International, Olen, Belgium). Each foot was subdivided into 10 zones and peak pressure, force-time integral as a percentage of total FTI, and contact time as a percentage of total stance time was estimated. The minimum duration of follow-up was 24 months (mean: 68.3 ± 20.3 months). The data were compared with 20 age- and weight-matched healthy controls. Despite clinical and radiographic examinations showing satisfactory results according to modified McKay and Severin criteria, significant differences in plantar pressure parameters were identified between the affected limbs, the unaffected limbs, and normal controls. No significant differences were found between patients classified as "excellent or good" and those rated as "fair" according to the modified Severin criteria. Pedobarographic results showed the existence of the residual plantar pressure deviations during walking in patients treated with PPO for unilateral DDH. Longer follow-up will be needed to more fully evaluate the effect of these deviations on gait.

The safety and efficacy of a transarticular pin for maintaining reduction in patients with developmental dislocation of the hip undergoing an open reduction

BACKGROUND

Redislocation after an open reduction for develpmental dislocation of the hip is relatively common. The purpose of this study was to determine if the use of a transarticular pin (TAP) is safe and effective in maintaining reduction.

METHODS

A total of 578 patients (645 hips) were reviewed after an open reduction, mean age at the time of surgery was 2.1 years. In 621 cases a smooth Kirschner wire was placed across the joint. The rates of redislocation, avascular necrosis (AVN), and other complications were determined. AVN was classified according to Kalamchi et al. Outcome was determined at a minimum of 6 years using the Severin classification.

RESULTS

Redislocation occurred in 27 cases (4.1% rate), 24 had a TAP (3.8%) and 3 did not (12.5%). AVN was observed in 127 cases (19.7%), it was type I in 73 cases, type II in 38 cases, type III in 14 cases, and type IV in 2 cases; AVN was seen in 123 cases which had a TAP (19.8%) and 4 cases which did not (16.7%). Analyzing pin placement: when it was in the inferior third of the neck the rate of AVN was 15.2% (32/211), in the middle third it was 21.7% (71/326), and in the superior third it was 28.6% (24/84). According to the Severin classification for the hips with a TAP, 496 were type I or II (79.8%), 113 were type III (18.2%), 10 were type IV (1.6%), and 2 were type V (0.3%); in the group without a TAP 19 cases were type I or II (79.2%), 4 were type III (16.7%), and 1 was type IV.

CONCLUSIONS

The use of a TAP was effective in maintaining reduction and was not associated with significant morbidity. Placing the pin in the inferior third of the neck was associated with the lowest rate of AVN.

LEVEL OF EVIDENCE

Level IV--therapeutic.

Hip flexion deformity improves without psoas-lengthening after surgical correction of fixed knee flexion deformity in spastic diplegia

BACKGROUND

It is unclear if psoas lengthening surgery is required in the treatment of patients with cerebral palsy (CP) with hip flexion deformity and previous studies show equivocal results with regard to functional outcome.

METHODS

This study retrospectively assessed 12 patients with a diagnosis of spastic diplegia who underwent single event multilevel surgery in order to correct deformities in the sagittal plane distal to the hip. Both clinical and instrument gait analysis results were recorded preoperatively, at one year (short term) and at five years (mid term) postoperatively.

RESULTS

Clinically measured hip and knee movement improved at both short and mid term follow up. Correlations of clinically measured maximum hip and knee extension were significant at all three time points. Angles at terminal stance/toe off for hip and knee from kinematic data also showed significant correlations at all three time points.

CONCLUSIONS

Our study demonstrates that the hip flexion deformities encountered in these patients will improve spontaneously when the distal fixed knee flexion deformity is surgically corrected. Therefore correction at the knee allows the ground reaction force to assume a more normal position resulting in correction at the hip over time. This then removes the need for surgery at the hip level. This fact is especially important when applied to psoas lengthening as this procedure can cause significant reduction in propulsion power.

Residual gait deviations in adolescents treated during infancy for unilateral developmental dysplasia of the hip using Pemberton's osteotomy

Early reduction using Pemberton's osteotomy has been suggested for treating DDH but no data on the long-term residual gait changes in such patients are available in the literature. This study aimed to bridge the gap by performing quantitative gait analysis on eleven females (age: 10.6 ± 1.0 years) who were treated for unilateral DDH using open reduction with Pemberton's osteotomy at 1.6 ± 0.5 years of age, and eleven age-matched healthy controls. Walking at a normal speed, the Pemberton group displayed significantly more anterior tilt, hiking at the affected side and rotation towards the unaffected side of the pelvis, and more knee flexion and ankle dorsiflexion in the affected limb. With this asymmetrical gait, they appeared to reduce the demands on the hip flexors and abductors, and knee extensors in the affected limb, which might have been involved during the osteotomy, but increased compensatory efforts from the hip extensors, ankle plantarflexors and knee flexors in the unaffected limb.

Adolescents after Pemberton's osteotomy for developmental dysplasia of the hip displayed greater joint loading than healthy controls in affected and unaffected limbs during gait

Patients after reduced developmental dysplasia of the hip (DDH) are at higher than normal risk of developing avascular necrosis (AVN) of the femoral head and degenerative hip osteoarthritis (OA) that are closely related to abnormal loadings. We aimed to determine the lower limb loadings in adolescents after Pemberton's osteotomy for unilateral DDH. Eleven females (age: 10.6 ± 1.0 years), who had received Pemberton's osteotomy for unilateral DDH at 1.6 ± 0.5 years of age, and 12 age-matched healthy controls were studied using gait analysis. Compared to the normal controls, the patients were displayed greater peak axial forces at the hip, knee, and ankle in both limbs, with greater loading rates in the ground reaction force (GRF) and at the hips (p < 0.05 for all comparisons). The increased rates of repetitive loading around heel strike in both hips suggest that patients treated for unilateral DDH using Pemberton's osteotomy may be at higher risk of premature hip OA. The increased axial forces at the affected hip may be a contributing factor to the development of AVN of the femoral head in these patients, especially when incomplete coverage, insufficient congruency, and/or damaged articular surfaces remain after the osteotomy. Therefore, monitoring the loading condition at the hip is necessary for a more accurate assessment of the risk of developing joint pathology in patients after reduced DDH.

Preoperative botulinum toxin test injections before muscle lengthening in cerebral palsy

BACKGROUND

Muscle weakening is a well-known side effect of muscle-tendon lengthening. Botulinum toxin A (BTX-A) weakens the muscle temporarily by blocking the neuromuscular junction. Hence application of the drug is a logical step to test whether weakness deteriorates function prior to an operation. In the present study, BTX-A application is used to test preoperatively whether the gait pattern depends on the strength of the tested muscle. Since 1999, instrumented gait analysis, including kinematic, kinetic, and dynamic electromyographic data, is routinely used to define the individual surgical program.

METHODS

In our series of 110 consecutive patients with cerebral palsy (CP) considered for surgical muscle lengthening from 1999 to 2008, BTX-A was applied to identify patients at risk for functional deterioration. Gait analysis was repeated 6 weeks (maximum effect of BTX-A) and 12 weeks (follow-up) after the test injection to check for loss of joint control (excessive ankle dorsiflexion, knee flexion, increased anterior pelvic tilt).

RESULTS

In all, 20.9% (n = 23) showed deterioration in gait after preoperative BTX-A test injections (n = 112, two patients had two test trials) in all muscles considered for lengthening. As a consequence, their lengthening surgery was canceled. A total of 68 patients underwent surgery as planned, and in none of them did gait function deteriorate. These clinical data were compared to those of a historical group (n = 105) before this test, where 18% showed functional deterioration after surgery. The similar percentage of patients filtered out by the test suggests that there could be a context to the number of poor results in the historical group.

CONCLUSIONS

We conclude that preoperative BTX-A test injection is a reliable tool for filtering out patients with risk of deterioration after muscle lengthening surgery in patients with CP and can be helpful to avoid poor outcomes.

The evaluation of hip muscles in patients treated with one-stage combined procedure for unilateral developmental dysplasia of the hip: part II: isokinetic muscle strength evaluation

BACKGROUND

To assess the isokinetic muscle strength (IMS) of hip flexor and extensor muscles in patients treated with one-stage combined procedure for developmental dysplasia of the hip and analyze the effect of the status of hip muscles on IMS.

METHODS

Twenty-two patients were included in the study. The mean age was 154.4+/-34.6 (110-216) months and the mean follow-up was 112.6+/-32.0 (68-159) months. All patients underwent complete tenotomy of the iliopsoas muscle to ease open reduction and had excellent results according to the modified McKay criteria of Barrett and type I hips according to the radiologic criteria of Severin. All patients had earlier magnetic resonance imaging examination that revealed reattachment of the iliopsoas in 7 (32%) patients. IMS measurements were performed at 120 degrees/s and 240 degrees/s. The peak torque (PT), PT angle, total work (TW), and average power (AP) values of operated and nonoperated hips were recorded separately for flexors and extensors.

RESULTS

For flexors, TW and AP values were lower at the operated hip when compared with the nonoperated hip at both angular velocities. PT was only lower at the operated hip at 120 degrees/s. For extensor muscles, PT, TW, AP, and PT angle showed no statistically significant difference at either angular velocity. For flexors, the PT deficit between the operated and nonoperated hips at 120 degrees/s and 240 degrees/s was measured as 15.3% and 8.0%, respectively. There was no difference between the flexor muscles of operated and nonoperated hips considering PT, TW, and AP at both angular velocities in patients with reattachment. The IMS deficit of flexor muscles at 120 degrees/s was significantly higher in patients without reattachment of iliopsoas when compared with those with reattachment, and correlated to the widths of the iliopsoas muscle at levels II and III.

CONCLUSIONS

Assessing the results of surgical treatment of DDH with conventional radiologic and functional criteria might be misleading in some patients with excellent results because some of these patients, particularly those without reattachment of the iliopsoas muscle, experience significant weakness in hip flexion.

The evaluation of hip muscles in patients treated with one-stage combined procedure for unilateral developmental dysplasia of the hip: part I: MRI evaluation

BACKGROUND

To assess the status of hip flexor and extensor muscles with MRI in patients with unilateral developmental dysplasia of the hip (DDH) after walking age who were treated with one-stage combined procedure.

METHODS

Twenty-two patients operated upon with one-stage combined procedure for unilateral DDH were included in this study. All patients underwent complete tenotomy of the iliopsoas muscle hindering open reduction. All patients showed excellent results according to the modified McKay criteria of Barrett and type 1 hips according to radiologic criteria of Severin at the latest follow-up. MRI assessment of iliopsoas, rectus femoris, tensor fasia lata, sartorius, and gluteus maximus muscles was performed and muscles of the hip that was operated upon were compared with the hip that was not. In addition, the iliopsoas muscle was examined for reattachment and the effect of reattachment was evaluated.

RESULTS

Mean age was 154.4+/-34.6 (110 to 216) months. Mean follow-up was 112.6+/-32.0 (68 to 159) months. Reattachment of the iliopsoas was observed in 7 (32%) patients, with no significance in terms of age, postoperative follow-up period, or the duration of the postoperative period. Atrophy in the hip that was operated upon was significant in iliopsoas, rectus femoris, tensor fasia lata, and gluteus maximus muscles when compared with the hip that was not. No significance was detected in the sartorius muscle between hips that were operated upon and those that were not. Cross-sectional areas of tensor fascia lata, rectus femoris, sartorius, and gluteus maximus muscles were not significantly different between patients with and without reattachment of iliopsoas. The width of the iliopsoas muscle was significantly lowered in patients without reattachment.

CONCLUSIONS

Patients with DDH treated with combined procedures including complete iliopsoas tenotomy do not have hip muscles similar to hip muscles that have not been operated upon, despite excellent radiologic and clinical results. These patients can be affected by muscular changes in the long term. Follow-up by conventional radiologic and clinical criteria alone may not be enough, and patients may have problems, as in our series, that cannot be detected by conventional radiologic and clinical assessments.

LEVEL OF EVIDENCE

Level IV, Therapeutic case series.

No detectable major changes in gait analysis after soft tissue release in DDH

The iliopsoas and adductor tendons are often soft tissue barriers obstructing relocation of the femoral head into the acetabulum and are frequently released to obtain reduction. We assessed whether posteromedial soft tissue release including sectioning of the adductor longus and iliopsoas tendons would lead to alterations in joint angles and moments of the hip joint or other major changes in the gait pattern. We conducted 3-D quantitative gait analysis of 10 patients (mean age, 8.1 years) who had unilateral and surgically treated DDH before the age of 18 months. The mean single support time was shorter in the unaffected side of the patients than in the healthy control group. Mean pelvic excursions in both frontal and sagittal planes and maximum knee extension at stance of the affected and unaffected sides were higher in the patients than in the control group. Peak hip flexion moment during swing phase was somewhat reduced, and the hip moment crossover point from extension to flexion was slightly delayed in both the affected and unaffected sides. We could not identify an explanation for the slight deviations due to limited data. However, sectioning of the adductor longus and iliopsoas tendons in DDH patients under 18 months old did not appear to lead to major objective clinical gait alterations.

LEVEL OF EVIDENCE

Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Effect of selective dorsal rhizotomy in the treatment of children with cerebral palsy

OBJECT

In this investigation the authors compared impairment and functional outcomes between two groups of children with cerebral palsy (CP): one group underwent selective dorsal rhizotomy (SDR) followed by intensive physical therapy (PT), and the other group underwent the latter only (PT group). Data from an age-matched group of children without disability (nondisabled [ND] group) were also collected.

METHODS

Data pertaining to the 68 children with CP were collected before any intervention and again 8 and 20 months afterwards. Data regarding the 40 children in the ND group were collected in a single session.

CONCLUSIONS

Although patients in both groups with CP were weaker than those in the ND group, they did have strength gains. Gait speed in the SDR-PT group was slower than that in the ND group preoperatively but not at 20 months postoperatively. Gait speed in the PT group remained slower than that in the ND group. The pre- to postoperative change in the Gross Motor Abilities Estimate score was significantly greater in the SDR-PT group than in the PT-only group. An effective treatment for children with CP, SDR offers gains in strength, gait speed, and overall gross motor function.

Muscle strength recovery and its effects on outcome after open reduction and internal fixation of acetabular fractures

OBJECTIVE

To determine the relationship between muscle strength recovery and functional outcome in patients who were treated for an acetabular fracture via an anterior approach.

DESIGN

Case series.

SETTING

University Medical Center.

PATIENTS

Fifteen patients with a displaced acetabular fracture treated via an anterior, ilioinguinal approach were studied. Hip muscle strength of these patients was then compared with the muscle strength of a similar group of patients treated via a Kocher-Langenbeck approach (posterior approach). These patient groups were then combined and muscle strength recovery was compared with the functional outcome.

MAIN OUTCOME MEASURE

Primary outcome measures included hip muscle strength, including work (J/min) and maximum torque (Nm/kg) for abductors/adductors and flexors/extensors. Clinical outcome was assessed with the Musculoskeletal Function Assessment (MFA) questionnaire and the results correlated with muscle strength. Secondary outcome measures included adequacy of fracture reduction, radiographic grade, severity of heterotopic ossification, and range of motion of the affected and unaffected hips.

RESULTS

At an average follow-up of 44 months, patients treated via an anterior approach had an overall muscle strength deficit of 9%. Hip extension strength was affected to the least extent (6% deficit when compared with the unaffected hip) whereas abduction, adduction, and flexion strength was affected to a greater degree. For each measure the affected side was typically weaker than the unaffected side. The average MFA score for the anterior approach group was 17 (range, 0 to 47) with most patients reporting poorest results in those domains assessing activities of the arms and legs, and those involving life changes and feelings. When MFA scores were compared with the muscle strength, a relationship was found between hip extension/flexion work and maximum torque and hip adduction work and maximum torque and MFA score. For each of these muscle groups, patients reported worsening function with decreased muscle strength. Assessment of the most recent radiographs revealed 9 patients with an excellent radiographic grade, 3 patients with a good grade, 1 patient with a fair grade, and 2 patients with a poor grade. Hip range of motion was not statistically different when the affected hip was compared with the unaffected hip, and none of these variables correlated with outcome. Heterotopic ossification was found in 8 patients; 4 with grade 1, and 4 with grade 2.

CONCLUSIONS

Standardized muscle strength determination and completion of an MFA questionnaire provided a thorough evaluation of patients who had undergone open reduction and internal fixation of a displaced acetabular fracture. In these patients, hip muscle strength after operative treatment of a displaced acetabular fracture directly influences patient outcome. Therefore, in order to maximize the outcome of these patients, particular attention must be paid to postoperative muscle strengthening protocols and accurate and validated methods to assess strength and outcomes.

Tratamento cirúrgico do quadril displásico inveterado

Avaliamos 50 pacientes (57 quadris) com Displasia do desenvolvimento do Quadril Inveterada, divididos em 2 grupos de acordo com o tratamento aplicado. O grupo A foi constituído por 20 pacientes (24 quadris), 2 masculinos e 18 femininos, com média das idades = 65,92m nos quais a tração pré-operatória foi utilizada por 2-4 semanas, quando realizou-se a redução cruenta, a osteotomia de Salter ou a de Chiari e a osteotomia intertrocantérica de encurtamento e rotação-varização. O grupo B foi composto por 30 pacientes (33 quadris), 1 masculino e 29 femininos, com média das idades = 52,88m. Nestes, foi realizada uma osteotomia femoral diafisária para encurtamento, redução cruenta e osteotomia de Salter ou Chiari. Para a avaliação radiográfica analisamos: ângulo de Wiberg, necrose avascular, esfericidade da cabeça femoral; discrepância entre os membros inferiores. Para a avaliação clínica consideramos: dor, Trendelenburg, exame neurológico e arco de movimento. Observamos, clinicamente, 14(58,33%) bons resultados e 10(41,67%) regulares no grupo A e 23(69,70%) bons e 10(30,30%) regulares no B. Radiograficamente, foram considerados 9(37,50%) bons, 5(20,83%) regulares e 10(41,67%) maus resultados no grupo A e 23(69,70%) bons, 5(15,15%) regulares e 5(15,15%) maus resultados no B. Após análise estatística, observamos melhores resultados no grupo B.

Comparison of Three Heel Cord Surgeries in Children with Cerebral Palsy

This nonrandomized prospective descriptive study compared outcomes of three isolated heel cord surgeries in children with spastic diplegia cerebral palsy (CP): (1) heel cord advancement (HCA), (2) heel cord lengthening according to Vulpius (HCL-V), and (3) heel cord lengthening according to White (HCL-W). Thirty-two children were tested prior to and approximately 1 year after undergoing one of the three surgeries. Objective measures were collected for ankle passive and active range of motion, gross motor function measure (GMFM), and gait. All surgeries indicated significant improvements in end range passive and active ankle dorsifiexion, GMFM, and dorsifiexion during gait. Gait speed was significantly improved for the HCA group, but appeared to be the result of maturity. Gait speed for the HCL-V and HCL-W groups was unchanged. The study was the first to directly compare three heel-cord-lengthening surgeries.

Long-term results after open reduction of developmental hip dislocation by an anterior approach lateral and medial of the iliopsoas muscle

The technique of and especially the approach to open reduction of developmental dislocation of the hip are still a matter of discussion. The anterior approach, first lateral and then medial to the iliopsoas muscle, was described by Tonnis in 1978. A follow-up investigation to adulthood has now been performed. Eighty-seven children (118 hips) out of 105 children (83%) who underwent open reduction of developmental dislocation of the hip before the age of 4 years were reinvestigated 10-21 years after the operation. An anterior approach first lateral, then medial to the iliopsoas muscle was chosen, because this offers the best access to the joint. Additional operations including transiliac osteotomy for acetabuloplasty, shortening osteotomy, and femoral osteotomies were performed as necessary. In 92 (78%) of the 118 hips studied the CE angle exceeded 25 degrees and in 98 hips (83%) the VCA angle exceeded 25 degrees. Critical CE angles between 20 and 25 degrees were found in 14% of the hips, and critical VCA angles in 4%. Residual dysplasia (<20 degrees) was found in 8 and 13% of the hips, respectively. Avascular necrosis according to Hirohashi was observed after operation in grade 1 in 5.9% and grade 2 in 1.7%. No necrosis was found following shortening osteotomy of the proximal femur. The anterior approach, first lateral, then medial to the iliopsoas muscle, offers an optimal access to the medial parts of the joint with control of reduction, protects the vasculature of the femoral neck, and allows simultaneous postero-lateral capsulorrhaphy and pelvic osteotomies.

Spasticity, strength, and gait changes after surgery for cervical spondylotic myelopathy: a case report

STUDY DESIGN

A case report with repeated measures is presented.

OBJECTIVE

To describe an objective method for evaluating changes in upper- and lower-extremity spasticity and strength, as well as temporal and kinematic gait variables, after surgical intervention for cervical spondylotic myelopathy.

SUMMARY OF BACKGROUND DATA

Degenerative cervical spinal disease is a common disorder, with some form of spondylosis demonstrated radiographically in more than 80% of those older than 55 years. Normative pre- and postoperative objective data quantifying spasticity, strength, and gait do not exist.

METHODS

A 65-year-old woman underwent C2-C3 anterior cervical discectomy and fusion for progressive myelopathy secondary to a spondylosis and disc herniation. The measure for spasticity and strength at the ankles and elbows and a gait analysis were collected before surgery and at 11 days, 3 and 6 months after surgery. Spasticity and strength were assessed using a dynamometer, and a six-camera video system was used to record the gait.

RESULTS

Preoperative left elbow flexor spasticity was more than 10 times greater than the values for the able bodies. It was reduced to normal levels after surgery. Substantial presurgery weakness was present in the elbow flexors and extensors bilaterally. Elbow extensor strength was at able-body levels after surgery. Gait speed was 57% of the able-body level before surgery and 78% of the able-body level 6 months after surgery.

CONCLUSIONS

This case study demonstrated the role of biomechanics in characterizing impairments associated with cervical spondylosis and its surgical intervention. Measures for spasticity, strength, and gait taken before and after surgery indicated a favorable outcome. This report provides a foundation for the continued use of biomechanical methods to measure changes in function and impairments associated with surgical intervention of cervical spine disorders.

Failures of open reduction in developmental dislocation of the hip

Eight patients with the same number of developmental dislocated hips were initially treated with open reduction through an anterolateral approach. The hips then became dislocated again. There were six girls, with a mean age at first open reduction of 13.3 months. We treated the hips with a new open reduction through an anteromedial approach. A constricted anteromedial capsule was always found as the main factor; all had an intact anteromedial capsule, there was an inverted transverse ligament in three cases and a very tight psoas tendon in another three cases. All were reduced, without complications and with only one simultaneous bone procedure. Risk of avascular necrosis and residual dysplasia could not be evaluated with this follow-up. We conclude that in any open reduction for developmental dislocation of the hip the surgeon must consider a release of the anteromedial capsule, which we have found to be the most important factor in technical failures.

Functional outcome after isolated acetabular fractures

OBJECTIVE

To evaluate objectively the effectiveness of current surgical management of displaced acetabular fractures. To provide insight into how these evaluation methods can be used to identify areas in which improvements in surgery and rehabilitation can be pursued to improve patient outcomes.

DESIGN

Consecutive case series.

SETTING

University medical center.

PATIENTS

Fifteen patients were studied, each with an isolated, displaced acetabular fracture treated with a Kocher-Langenbeck approach.

MAIN OUTCOME MEASURES

Primary outcome measures included hip muscle strength, including work (Joules/minute) and maximum torque (30 degrees/second) for abductors/adductors and flexors/extensors. Gait analysis of patients and able-bodied cohorts, including stride length, speed, and cadence, were also assessed. Motion analysis during gait was also studied for each body segment, including the trunk, pelvis, hip, knee, and ankle, in the sagittal, frontal, and axial planes. Motion data for the affected side was compared with motion data for the unaffected side, and linear gait findings for the study patients were compared to able-bodied cohorts. An assessment of clinical outcome was performed by completion of a validated Musculoskeletal Function Assessment (MFA) questionnaire and the were results correlated with muscle strength and gait analysis. Secondary outcome measures included adequacy of fracture reduction, radiographic grade, the presence and severity of heterotopic ossification at the time of the most recent follow-up, and passive range of motion of the affected and unaffected hips.

RESULTS

No statistical differences in muscle strength for each of the major muscle groups were found when the affected limb was compared with the unaffected limb. No statistical differences were found between the study patients and the able-bodied cohorts with regards to stride length, gait speed, and cadence. The only significant difference found in body segment position was trunk inclination. When the study patients were compared with able-bodied cohorts, the patients tended to walk with greater forward inclination of their trunks; this was true for all phases of gait. Total MFA scores averaged 22 (range, 0-57). Patients could be separated into two separate groups based on their total MFA score. One group (n = 6) had an average MFA score of 7 (range, 0-10), while a second group (n = 9) had an average MFA score of 32 (range, 12-57). The scores of study patients as a whole, and those of each individual group of patients, were compared with known MFA scores for nonpatients and patients in the Orthopaedic Trauma Association/Association for the Study of Internal Fixation (OTA/AO) injury group (hip and thigh). When the muscle strengths of these two groups of patients were compared, all hip flexion and extension variables were significantly weaker in the group with an average MFA score of 32, whereas none of the gait variables were different between the two groups. At an average follow-up of 24 months, seven patients had an excellent radiographic grade, four patients had a good grade, two patients had a fair grade, and two patients had a poor grade. These radiographic grades were in contrast to achieving an anatomic reduction in eleven patients, a satisfactory reduction in three patients, and an unsatisfactory reduction in one patient. Heterotopic ossification was found in eight patients, four patients had Grade 1, and four patients, had Grade 2. No statistically significant differences were observed when each MFA group was compared with each of these radiographic variables. Passive hip range of motion was not statistically different when the affected hip was compared with the unaffected hip.

CONCLUSIONS

Standardized muscle strength determination, gait, and motion analysis, and completion of an MFA questionnaire provided a thorough and revealing evaluation of patients who have undergone open reduction and internal fixation (ORIF) of a displaced acetabular fracture. Minimal alterations in body posture and affected limb motion were present in patients displaying relatively normal gait parameters, including stride length, speed, and cadence. Despite dissection of the hip musculature during surgery, normal muscle strength recovery was possible after operative repair of these acetabular fractures. However, functional outcome, as determined by MFA scores, was considerably poorer in those patients with significantly weaker hip flexion and extension strength, compared with those of patients with more desirable MFA scores. Based on the current data, it appears that the use of these and similar evaluation instruments can allow determination of factors that negatively affect outcome (hip flexion and extension strength), which otherwise may remain unknown. It is possible that identification and treatment of these factors will improve the quality of life for patients after this type of injury.