Orthopaedic manifestations of Rett syndrome

We reviewed nine patients with Rett syndrome, a progressive encephalopathy that is being diagnosed more frequently in the United States. It occurs in females, causing mental deterioration, autistic behavior, and classic hand-wringing motion. The orthopaedic manifestations include scoliosis, lower extremity contracture, and coxa valga. Bracing and surgery are indicated to prevent or correct deformity and maintain ambulation.

Use of allograft bone for posterior spinal fusion in idiopathic scoliosis

Eighty-seven adolescents with idiopathic scoliosis (77 female and 10 male patients) who underwent posterior spinal fusion with instrumentation using only allograft bone for graft material were evaluated retrospectively. The average age at surgery was 14 years 3 months. Each patient had a minimum 2-year followup, with an average of 3 years 5 months followup. The average preoperative curve was 59 degrees thoracic (range, 31 degrees-90 degrees) and 52 degrees lumbar (range, 21 degrees-65 degrees). At followup, the thoracic curve measured an average of 35 degrees and the lumbar curve measured an average of 34 degrees. The average loss of correction from the immediate postoperative period until last followup was 6.5 degrees or 11% in the thoracic curve and 10 degrees or 19% in the lumbar curve. There were seven reoperations; one of these reoperations involved repair of a pseudarthrosis. There was one clinical infection. The typical patient had a 2-ounce allograft at an average cost of $800. The patients' average loss of correction, complication rate, and reoperation rate compare favorably with results reported in other series using autograft bone. The authors of this study showed the ability of allograft bone to produce reliable results with a satisfactory outcome. The potential advantages of using allograft must be weighed against the potential disadvantages before recommending its routine use.

Orthotic treatment of infantile tibia vara

Difficulty differentiating physiologic genu varum from early Blount's disease persists. Drennan's metaphyseal-diaphyseal (MD) angle remains the most consistently valuable radiographic parameter despite measurement error. Clinical risk factors also should be considered. All patients receiving orthoses for genu varum since 1985 were reviewed. The focus of the study was those patients with an MD angle of >16 degrees or between 9 and 16 degrees with a clinical risk factor for progression. Risk factors considered were ligamentous instability, obesity, asymmetry, and being female, black, or Hispanic. Thirty-eight patients with 60 tibiae were included. The success rate was 90%. Risk factors for failure (six cases) were instability, obesity, and delayed bracing. In cases with MD angles >16 degrees, the success rate was 86%. The results of orthotic treatment, restricted to patients meeting the stated parameters, represent improvement on the reported natural history.

Pathologic morphology of the dislocated proximal femur in children with cerebral palsy

We describe the gross and microscopic anatomic changes in the hip that result from the deforming forces in children with neuromuscular imbalance. Twelve dislocated proximal femora that had been resected from children with spastic diplegia or tetraplegia were evaluated with respect to their gross, microscopic, and radiographic structure. The epiphyses were wedge shaped with deformation of the femoral head apparent in all cases. In addition to a severe loss of articular cartilage, a furrowed erosion of epiphyseal bone suggested a sustained, blunt, band-like force across the surface of the hip where it opposed the acetabular labrum. The underlying physis of the capital femur was irregular with aberrant histologic structure, whereas that of the lesser trochanter was hypertrophic and angulated in a superior and anterior direction. A significant degree of valgus was not noticeable in most specimens. In summary, the spastic adductor and iliopsoas, responsible for the changes in the lesser trochanter, work in conjunction with the hip flexor and internal rotator muscles to subluxate the proximal femur. In the process, the superior rim of the acetabulum and capsule causes focal deformation of the superolateral femoral head, creating a fulcrum upon which the hip then progressively subluxates. The indentation locks the femoral head at the lateral acetabular margin, preventing complete dislocation, but leading to bone pain consequent to cartilage erosion.

Contiguous discitis and osteomyelitis in children

Magnetic resonance imaging of 16 patients with contiguous discitis and osteomyelitis provided a specific diagnosis and defined the anatomic extent of vertebral and soft-tissue involvement. Altered signal changes were evident in the disc, adjacent vertebra in the end plate and metaphyseal equivalent regions, and the anterior prevertebral tissues. Significant posterior spread and disc herniation were not evident. Fourteen patients had lumbar involvement; two had cervical involvement. The patients were followed-up for an average of 4 years 5 months. Scoliosis has developed in one patient, and four continue to have a loss of lumbar lordosis. By comparing serial roentgenograms, the mean decrease of disc-space height after the acute episode was 43% (range, 51-61%). There was no restitution of normal disc-space height at the latest follow-up roentgenogram in any of the patients. A 14% (average) narrowing of the vertebral foramina was evident in seven cases. In one patient, a fusion progressively developed 7 years after the acute episode (before full skeletal maturity). However, several patients appear to be progressing toward fusion of adjacent vertebra. A study of histologic specimens elucidated vascular anatomy of the immature vertebra that further explain the disease characteristics.

Ilizarov treatment of congenital pseudarthroses of the tibia

Eleven children with congenital pseudarthrosis of the tibia were treated with the Ilizarov device. This was successful in nine of 11 patients with an average of 322 days in the fixator and 1.6 additional surgeries. Two patients eventually had amputations. These results demonstrate this to be an effective tool for this complex condition, but amputation should be considered if union is not achievable with this method and other procedures have previously been attempted.

Residual bone cysts after correction of severe foot deformities with the Ilizarov technique

Fourteen patients with severe foot deformity treated by application of the Ilizarov device were evaluated for residual bone changes in the foot. Cyst formation was noted in all patients, most commonly in the base of the fifth metatarsal. These cysts did not develop in the area of bone penetrated by the wires. In an average follow-up of 3.4 years after device removal, the cysts did not resolve. Histologic examination of one resected cyst demonstrated an empty lacuna with no cell lining, as seen in the "cysts" associated with osteoarthrosis.

Tibia valga after proximal metaphyseal fractures in childhood: a normal biologic response

Seventeen children with 19 proximal tibial metaphyseal fractures were followed-up between 2 and 7 years after injury. Detailed measurements of the metaphyseal/diaphyseal/metaphyseal distances medially and laterally on the injured and noninjured sides demonstrated overgrowth. In four patients, the medial distance of the injured tibia was longer than the lateral distance, which was the same distance as the uninjured tibia. In 11 patients, there was an overgrowth of both the medial and lateral sides of the injured tibia, compared to the unijured tibia, and in each instance, the medial distance of the injured tibia was always longer than the lateral. In a patient with bilateral metaphyseal fractures, the medial length exceeded the lateral length in both tibias. In the child with metaphyseal and diaphyseal fractures, the medial side of the tibia with the metaphyseal fracture was the longest of the four measurements. In five of six patients with Harris lines, there was distal as well as proximal tibial metaphyseal overgrowth, but the distal line was always parallel to the physis and did not contribute to the valgus angulation. Thus there was not only a generalized increased growth proximally and distally, but there also was an eccentric proximal medial overgrowth in every patient.

Management of pediatric limb length inequality

The treatment of limb length inequality in pediatric patients is a complicated and long-term procedure, and careful evaluation is necessary over several visits. A team approach with an involved family is essential, as is knowledge and familiarity with the various conservative and surgical options. Treatment must not be rushed, and it is important to realize that not everyone needs a lengthening. Soft tissue and osseous complications are significant in these procedures, so shoe lifts and shortening procedures are attractive alternatives in smaller discrepancies. This condition is in a growing child and therefore not static. Future growth may dictate that procedures be staged. Most importantly, we must carefully equalize limb length in a manner that is neither physically nor emotionally scarring (Fig 26). These children are best served by a well-thought out plan that minimizes both kinds of trauma, decreases hospital and treatment time, and involves the family and patient in the planning and understanding of the proposed intervention and potential complications.

The embryology of lower-extremity torsion

The presence of torsional deformities in the lower extremities of otherwise normal children is based on a variety of developmental processes. With intrauterine maturation, both rotation and external compression of the extremities take place. These forces result in the normal molding and final position of the limbs. Torsion of the extremities is, thus, a normal embryological process. It is imperative for the treating physician to understand these factors in human development to decide which cases are significant deviations from normal torsion. Knowledge of the embryology and natural history of these conditions is a key to appropriate treatment of patients with torsional or angular malalignments.

Hypertension following orthopaedic surgery in children

Five patients developed hypertension after undergoing orthopaedic surgery. Three of four patients in whom serum renin was assayed had significant elevation, suggesting a possible renal-mediated etiology. Two patients required the addition of an angiotensin-converting enzyme (ACE) inhibitor to control hypertension while continuing the prolonged orthopaedic procedures. The need for careful blood-pressure monitoring of children undergoing orthopaedic surgery is emphasized in this article.

Overgrowth management in Klippel-Trenaunay-Weber and Proteus syndromes

Twenty-eight patients with limb overgrowth and the diagnosis of Klippel-Trenaunay-Weber or Proteus syndromes were evaluated retrospectively. These disorders are part of the phakomatosis spectrum of syndromes. The orthopedic problems consisted of asymmetric limb overgrowth, localized gigantism, angular deformities, scoliosis, vascular malformations, and skin anomalies. Systemic abnormalities are common and deserve full evaluation before treatment. Surgical treatment consisted of epiphysiodesis, osteotomies, debulking procedures, and amputation. Mixed results were obtained with surgery, and conservative or supportive treatment should be the primary mode of orthopedic care.

Use of the reciprocating gait orthosis in myelodysplasia

There are advantages to an upright posture and ambulation in pediatric myelodysplasia patients. The reciprocating gait orthosis (RGO) is a useful tool to enable this activity in selected individuals. We evaluated the long-term usage, pitfalls, and contraindications of this orthosis. Mean daily usage was 6.9 h/day, requiring an average of 10 min to don or doff; all patients required assistance. Obesity, advanced age, lack of patient or family motivation, scoliosis, and spasticity were significant negative factors in long-term usage of the RGO. Good upper extremity strength, trunk balance, previous standing or walking, and active hip flexion were important positive variables. Eleven of 21 patients did not persist with long-term usage of this orthosis, averaging 25.8 months of usage. An energy study was performed on three patients, comparing the efficiency of reciprocating gait and swing-through gait. All three were more energy efficient and two were faster with the swing-through gait but each preferred the reciprocating pattern. Care should be taken when selecting patients for RGO usage because not all children with myelomeningocele are able to function effectively with this orthosis.

Cotrel-Dubousset instrumentation. Results in 52 patients

Fifty-two posterior spinal fusions were performed for pediatric idiopathic, congenital, and neuromuscular scoliotic curves. Cotrel-Dubousset instrumentation was used in all patients. Nine had prior anterior spinal releases and fusions. The patterns were mixed, with a predominance of right thoracic curvatures. The average preoperative curve measured 60.6 degrees, with correction to 29. Seven patients required revision surgery, and 17 wore orthoses after operation. There were 17 complications in this group, including hook pullout, prominent hardware, infection, pseudarthrosis, and two cases of broken Cotrel-Dubousset instrumentation rods. Fatigue failure of this instrumentation, secondary to pseudarthrosis, has not been reported previously, and these two cases are presented in detail. The operative morbidity and difficulty were increased in the larger idiopathic curves and in neuromuscular and congenital scoliosis. Cotrel-Dubousset instrumentation is an overall excellent tool for the multiplanar correction of scoliosis and is amenable to revision surgery.

Caudal regression: a review of seven cases, including the mermaid syndrome

Caudal regression consists of sacral agenesis combined with variable lower extremity deformities. The patients have contractures of the lower extremities, hip dislocations, neurologic impairment, and spine instability. Treatment consists of soft tissue releases, osteotomies, or orthotics. The goal of orthopaedic intervention is proper seating and standing, which may be achieved without amputation. In our patients, the lower extremity deformities were corrected surgically, but long-term function is unknown. We report the problems and treatment of seven patients with caudal regression syndrome, including the only known survivor with sirenomelia (mermaid syndrome), who underwent separation of the lower extremities.

Nail patella syndrome: a review of 44 orthopaedic patients

Nail patella syndrome is a rare dysplasia with characteristic findings of finger nail abnormalities, hypoplastic patellas, radial head dislocations, and iliac horns. We reviewed the problems and treatment of 44 patients with this syndrome from 13 Shriners Hospital units. The inheritance pattern is autosomal dominant, with foot abnormalities as the chief presenting complaint. All patients were ambulatory. Twenty of the patients underwent knee operations, and 24 underwent operations to correct foot and ankle deformities. Knee extensor realignments and foot posteromedial releases had overall good results. Knee flexion contractures required full posterior capsular releases. Elbow reconstructive procedures were rarely indicated.

Hypoplastic clavicles and lateral scapular redirection

Three patients with bilateral hypoplastic clavicles and anterolateral displacement of the shoulders and scapulas on the thoracic cage are described. One patient had no family history of the disorder. The mother of the other patient had the same condition, suggesting an autosomal dominant inheritance pattern. In all three patients, the clavicle was underdeveloped and the scapula was redirected onto the lateral rather than the posterior thorax, bringing the entire shoulder forward. None of the patients have any significant functional restriction.

Radiographic changes in arthrogrypotic knees

We evaluated the knees of 62 patients with arthrogryposis multiplex congenita radiographically. Abnormal radiographs were noted in 34. The abnormalities consisted of both congenital and chronic changes secondary to long-standing clinical deformities including patellar elongation, malposition, flattening of the femoral condyles, joint incongruity, tibial plateau irregularities, tibial and femoral fractures, fibula hypoplasia, soft-tissue thickening, valgus deformity, and dislocation. The radiographic findings were consistent with the degree of longstanding physical deformity and can be used as a guide to the severity of the condition and the need for treatment.

Operative treatment of congenital pseudarthrosis of the clavicle

Eight children were treated operatively with resection of fibrous pseudarthrosis and sclerotic bone ends, careful dissection and preservation of the periosteal sleeve to maintain continuity, and approximation of bone ends. None had additional bone grafts or internal fixation. All had bridging ossification 6-8 weeks postoperatively, and all were solidly healed by 14 weeks after surgery. Follow-up has ranged from 2 to 14 years, with no evidence of recurrence. Remodeling of the prominence occurred slowly in 2-5 years, with the distal clavicle variably underdeveloped in all patients. Early resection of fibrous pseudarthrosis probably does not require the extensive grafting and internal fixation that has been recommended for older children.

Extremity lengthening: results and complications with the Orthofix system

Twenty-four patients underwent extremity lengthening with the Orthofix for congenital, posttraumatic, or postinfective defects. All were followed to completion of treatment. Length gain and time of treatment were quite acceptable with the Orthofix, but the complication rate was high. This incidence was significantly greater than previously reported by the developers of the technique but equivalent to that reported with other methods.

Shark attack

Shark attacks are rare but devastating. This case had major injuries that included an open femoral fracture, massive hemorrhage, sciatic nerve laceration, and significant skin and muscle damage. The patient required 15 operative procedures, extensive physical therapy, and orthotic assistance. A review of the literature pertaining to shark bites is included.

Magnetic resonance imaging evaluation of congenital dislocation of the hips

Magnetic resonance (MR) images were obtained preoperatively and postoperatively for 12 pediatric patients with congenital dislocation of the hip (CDH). The images were compared with arthrograms and computed tomography scans. The MR images were more accurate in defining soft-tissue anatomy, hip position, and obstructive factors to relocation. MR imaging is an efficient diagnostic tool in CDH.

Orthopaedic manifestations in congenitally insensate patients

The spectrum of orthopaedic problems in eight congenitally insensate patients was reviewed. The conditions included congenital insensitivity to pain, Riley-Day syndrome, and Lesch-Nyhan syndrome. In each of these conditions, the patient has an abnormality of interpretation of painful stimuli or lacks normal pain avoidance, leading to self-inflicted damage. The orthopaedic problems and complications included fracture, self-mutilation, autoamputation, osteomyelitis, septic arthritis, Charcot joints, scoliosis, and dislocation. Effective management consists of early diagnosis and patient/parent education to prevent as many complications as possible. Fractures may be treated conservatively, while progressive scoliosis requires operative intervention. Osteomyelitis, septic arthritis, and Charcot joints require appropriate operative treatment.

Use of continuous passive motion in pediatric orthopedics

Continuous passive motion (CPM) was used to maintain or gain hip and knee range of motion in 18 postoperative or postinjury pediatric orthopedic patients. Continuous passive motion was started in the early postoperative period and augmented with physical therapy. The device was well-tolerated in 16 of the 18 patients. In all but one, motion was improved with a progressive decrease in joint pain. In these patients, CPM was found to be a valuable tool in rehabilitation, and did not interfere with traction, open wounds, nursing care, nor external fixation devices.

Foot and ankle deformities in arthrogryposis multiplex congenita

When 51 patients with arthrogryposis multiplex congenita followed an average of 12 years were reviewed, talipes equinovarus was the most common foot and ankle deformity. The best results were obtained by talectomy. The majority of tendo Achillis lengthenings, posteromedial releases, and triple arthrodeses were unsuccessful and were associated with a high complication rate. Congenital convex pes valgus was the second most common deformity. Surgical treatment by open reduction generally resulted in unsuccessful outcomes. Ambulation was achieved in 46 patients. Residual foot deformity was the primary reason for persistent difficulties in walking.