San Diego pelvic osteotomy in patients with closed triradiate cartilage

PURPOSE

A San Diego pelvic osteotomy is frequently used as part of the surgical treatment of neuromuscular patients with hip displacement. This short-term follow-up study assesses the effectiveness of this osteotomy in patients with closed triradiate cartilage compared with open triradiates.

METHODS

Retrospective review of 43 patients (44 hips) with neuromuscular hip disease who underwent a San Diego pelvic osteotomy to correct hip displacement. In all 24 hips had open triradiate cartilage at the time of surgery and 20 hips were closed. Centre edge angle (CEA), acetabular angle (AA) and Reimer's index (RI) were recorded from preoperative, postoperative and the latest follow-up radiographs and statistical analysis was performed.

RESULTS

CEA improved by 39° (7° to 69°) in the open group and 30° (9° to 80°) in the closed group from preoperative radiographs to postoperative, with no significant difference in improvement between groups (p = 0.084). There was no significant difference in AA between the open (improved by 11° (3° to 23°)) and closed (improved by 10° (4° to 21°)) groups (p = 0.65). RI improved from 61% to 11% in the open group and 51% to 12% in the closed group. There was no statistically significant difference between groups in RI at preoperative, immediate postoperative and final follow-up radiographs. At latest follow-up, CEA, AA and RI all remained relatively stable in both groups.

CONCLUSIONS

San Diego pelvic osteotomy is equally effective in improving radiographic parameters in neuromuscular patients with both open and closed triradiate cartilage. This study challenges the notion that closed triradiate cartilage is a contraindication to a San Diego pelvic osteotomy.

LEVEL OF EVIDENCE

III.

Unsteady walking as a symptom in type 2 diabetes mellitus: independent association with depression and sedentary lifestyle and no association with diabetic neuropathy

The purpose of this study was to look at the determinants of the unsteady walking (UW) symptom in patients with type 2 diabetes mellitus (T2DM) by defining if UW and/or the Diabetic Neuropathy Symptoms Score (DNSS) are associated with positive scores in Beck's Depression Inventory (BDI) and with a positive Michigan Neuropathy Screening Instrument score (MNSI). We evaluated 203 T2DM patients without visible gait disturbances. They were divided into UW (+) and UW (−) or DNSS (+) and DNSS (−) according to symptoms. We found a prevalence of 48.3% for UW (+) and of 63% for DNSS (+) in our sample. In univariate analysis, the presence of UW was significantly associated with waist circumference (P=0.024), number of comorbidities (P=0.012), not practicing physical exercise (P=0.011), positive BDI score (P=0.003), presence of neuropathic symptoms by the MNSI questionnaire (P<0.001), and positive diabetic neuropathy screening by MNSI (P=0.021). In multivariate analysis, UW (used as a dependent variable) was independently associated with a positive BDI score (P<0.001; 95%CI=1.01-1.03), T2DM duration (P=0.023; 95%CI=1.00–1.03), number of co-morbidities (P=0.032; 95%CI=1.01–1.37), and a sedentary lifestyle (P=0.025; 95%CI=1.06–2.5). The UW symptom and a positive DNSS are more closely related to a positive score for depression than to presence of neuropathy in T2DM.

Nematicidal activity of essential oils and volatiles derived from Portuguese aromatic flora against the pinewood nematode, Bursaphelenchus xylophilus

Twenty seven essential oils, isolated from plants representing 11 families of Portuguese flora, were screened for their nematicidal activity against the pinewood nematode (PWN), Bursaphelenchus xylophilus. The essential oils were isolated by hydrodistillation and the volatiles by distillation-extraction, and both were analysed by GC and GC-MS. High nematicidal activity was achieved with essential oils from Chamaespartium tridentatum, Origanum vulgare, Satureja montana, Thymbra capitata, and Thymus caespititius. All of these essential oils had an estimated minimum inhibitory concentration ranging between 0.097 and 0.374 mg/ml and a lethal concentration necessary to kill 100% of the population (LC(100)) between 0.858 and 1.984 mg/ml. Good nematicidal activity was also obtained with the essential oil from Cymbopogon citratus. The dominant components of the effective oils were 1-octen-3-ol (9%), n-nonanal, and linalool (both 7%) in C. tridentatum, geranial (43%), neral (29%), and β-myrcene (25%) in C. citratus, carvacrol (36% and 39%), γ-terpinene (24% and 40%), and p-cymene (14% and 7%) in O. vulgare and S. montana, respectively, and carvacrol (75% and 65%, respectively) in T. capitata and T. caespititius. The other essential oils obtained from Portuguese flora yielded weak or no activity. Five essential oils with nematicidal activity against PWN are reported for the first time.

Strategies of hip management in myelomeningocele: to do or not to do

Paralytic hip dislocation in myelomeningocele is common and can be a complicated problem. This review summarizes results of surgical techniques employed in this patient population in order to achieve and maintain reduction of paralytic hip dislocations. This review also examines the controversial question of whether or not hip surgery in patients with myelomeningocele provides improved functional results. Finally this paper suggest appropriate goals and recommendations for treatment of the paralytic hip dislocation in myelomeningocele.

Describing phytotoxic effects on cumulative germination

Phytotoxic studies strongly depend on evaluation of germination responses, which implies the need for adequate procedures to account for distinct aspects of the germinative process. For this, indices, comparisons among treatments at various times, and model fitting have been proposed. The objective of this work is to compare the three approaches and select the one providing the greatest insight and precision. Speed of germination, speed of accumulated germination, the coefficient of the rate of germination, comparisons at each determination time, including final germination, and the parameters of the Weibull function were examined. The Weibull function proved the best approach to describe the germination process, providing not only the same type of information about the speed of germination, with greater precision, but also additional information about the initiation and shape of the germination response curve.

Treatment of residual adduction deformity in clubfoot: the double osteotomy

Forefoot adduction is the most common residual deformity after clubfoot surgery. Surgical treatment of this deformity is often required for moderate and severe cases. This study reports the results of a closing wedge osteotomy of the cuboid and opening wedge osteotomy of the medial cuneiform in 39 feet. The average follow-up was 4.8 years. Clinical and radiographic improvement was seen in all patients, and no complications were seen. Surgery is advocated in children older than age 4, or when the medial cuneiform ossific nucleus is well developed.

Energy cost of walking in low lumbar myelomeningocele

The aim of this study was to determine whether it is more efficient for adolescents with low lumbar myelomeningocele (MM) to walk with a reciprocal or a swing-through gait pattern. Energy measurements for subjects with MM were compared for reciprocal and swing-through gait and also with an able-bodied control group. The rate of oxygen consumption (in milliliters per kilogram per minute) was higher for both the reciprocal and swing-through conditions compared with the control group, but there was no difference in the rate of consumption between the two modes of walking. Walking velocities (in meters per minute) were slower for both the reciprocal and swing-through conditions compared with the control group, with reciprocal walking significantly slower than swing-through gait. Oxygen cost (in milliliters per kilogram per meter) was higher for both the reciprocal and the swing-through conditions compared with the control group. Oxygen cost was higher for reciprocal walking than for swing-through gait. Swing-through gait proved to be the more efficient walking pattern in this group of subjects with MM.

Femoral shaft fractures in children treated with early spica cast

We retrospectively reviewed 51 patients aged 3-11 years with femoral shaft fractures selected for treatment with early spica cast immobilization. Shortening greater than 20 mm was the most common complication, occurring in 22 (43%) of the 51 patients. Factors associated with unacceptable shortening were shortening at the time of spica cast application greater than 10 mm, shortening greater than 20 mm at initial examination, and increasing age. Achieving less than 1 cm shortening at the time of cast application and close follow-up during the first 2 weeks after cast application are advised in order to achieve an acceptable final outcome.

Strategies for studies of neurotoxic mechanisms involving deficient transport of L-glutamate: antisense knockout in rat brain in vivo and changes in the neurotransmitter metabolism following inhibition of glutamate transport in guinea pig brain slices

This communication briefly reviews characteristics of glutamate transport in the central nervous system and is involved in the aetiology of slow neurodegenerative diseases. Data in the literature suggest that antisense oligonucleotides targeted against glutamate transporters and administered in vivo over a period of days could be used to test the hypothesis. Data from our laboratory have indicated that single intraventricular doses of antisense oligonucleotides can also results in significant reductions in the numbers of substrate binding sites associated with glutamate transporters and may even cause subtle changes in their characteristics. In order to study metabolism in brain tissue, we have used 13C-nuclear magnetic resonance spectroscopy to analyse extracts of slices of guinea pig cerebral cortex exposed to glutamate transport inhibitor L-anti,endo-methanopyrrolidine dicarboxylate (L-a,e-MPDC). The results have shown-for the first time in an experimental model that preserves the relationship between glia and neurones within the context of brain tissue-that inhibition of L-glutamate transport can exert a significant influence on neurotransmitter-related metabolism. These findings suggest that metabolic disturbances caused by deficient glutamate transport could play a significant role in the death of neurones under pathological conditions in vivo.

Angiotensin II in child urinary bladder: functional and autoradiographic studies

OBJECTIVES

To investigate the receptors for angiotensin II (AII, reported to be a potent contractile agent in human urinary bladder), using functional and autoradiographic techniques in child and adult bladder specimens. Materials and methods Bladder specimens were obtained from 61 children (aged 4 months to 12 years) undergoing ureteric reimplantation for vesico-ureteric reflux, and from 10 adults undergoing cystectomy. After overnight storage, the mucosa was removed and isometric contractions obtained from detrusor muscle strips in the presence of phosphoramidon (10 micromol/L). Only one concentration of AII was added to each preparation because of tachyphylaxis. The response to KCl (124 mmol/L) was 43% of that to carbachol (100 micromol/L). Sections of child bladder were radio-labelled with the ligand [125I]Sar1,Ile8-AII and binding sites visualized using emulsion autoradio- graphy.

RESULTS

The potency of AII was similar in child and adult detrusor strips, with mean (SEM) pD2 values of 6.9 (1.0) (n = 25) and 6.7 (0.2) (n = 9) respectively, and the maximum responses (to 10 micromol/L AII) rather low (39% and 49%, respectively, P > 0.05), compared with carbachol (100 micromol/L). There were no age- or gender-related differences. Responses to AII in strips from children under 3 years old were antagonized by the AT1 receptor antagonist losartan (1 micromol/L) but not by the AT2 receptor antagonist PD 123319 (1 micromol/L), indicating interaction with the AT1 receptor. Sections of child bladder radiolabelled with [125I]Sar1,Ile8-AII showed moderate specific binding over detrusor muscle and arterioles, with denser specific binding over subepithelial blood vessels. Specific binding was inhibited by co-incubation with losartan (10 micromol/L) but not with PD 123319 (10 micromol/L).

CONCLUSION

AII was a weak contractile agent of detrusor strips, with no significant differences in potency between child and adult bladder samples. These data show the presence of functional AT1 but not AT2 receptors in child detrusor smooth muscle.

Internal derotation osteotomy of the tibia: pre- and postoperative gait analysis in persons with high sacral myelomeningocele

Rotational deformities of the lower extremities are common in patients with myelomeningocele. In these situations, surgical correction is often necessary. We conducted a retrospective review of eight ambulatory patients with high sacral myelomeningocele and external tibial torsion who underwent 10 distal tibia and fibular internal derotation osteotomies. All patients had an increased valgus knee stress preoperatively. Pre- and postoperative three-dimensional gait analysis was used to evaluate coronal plane knee moments and dynamic sagittal plane knee motion. Postoperatively, a significant improvement in the abnormal internal knee varus moment (p < 0.005) as well as a significant increase in the stance phase knee extension (p < 0.01) was seen. Three patients had resolution of preoperative knee pain. We believe that patients with increased knee stress secondary to excessive external tibial torsion will benefit from a tibial derotation osteotomy that could delay or prevent the onset of late degenerative changes about the knee.

Binding characteristics of endothelin ET(A) receptors in normal and post-mortem rat lung

In control lung homogenates, optimal specific binding of [(125)I]endothelin-1 and minimal filter binding was achieved using 50 microg/ml bacitracin, 30 microM phenylmethylsulphonyl fluoride (PMSF) and 10 mM EDTA. In post-mortem tissue (8, 16, and 32 h), no significant changes were seen in ET(A) receptor affinity (K(d)) or number (B(max)): control and 32 h K(d) = 309 +/- 75, 225 +/- 32 pM and B(max) = 173 +/- 42, 185 +/- 17 fmol/mg protein, respectively. Autoradiographic binding sites for [(125)I]endothelin-1 were densely expressed on bronchiolar smooth muscle and parenchyma with moderate binding on epithelium and blood vessels. Histologic sections of post-mortem lung showed minimal deterioration of structures expressing ET(A) binding sites. Hence the ET(A) receptor is stable in the rat lung for up to 32 h post-mortem.

Quantitative autoradiography of Na+-dependent [3H]L-aspartate binding to L-glutamate transporters in rat brain: structure-activity studies using L-trans-pyrrolidine-2,4-dicarboxylate (L-t-PDC) and 2-(carboxycyclopropyl)-glycine (CCG)

Sodium-dependent binding of [3H]L-aspartate was studied in thaw-mounted horizontal sections of fresh-frozen (i.e. not fixed) rat brain. After the incubation with [3H]L-aspartate, the sections were exposed against a 3H-sensitive film and the resulting autoradiograms were evaluated by quantitative densitometry. Effects of several inhibitors were examined and their potency expressed as IC50 and nH. Together with previously published data, the present study supports the view that [3H]L-aspartate binding to fresh-frozen sections of rat brain represents interaction of the radioligand with the substrate-binding sites on glutamate transporters. The most potent inhibitors were (2S,3S,4R)-2-(carboxycyclopropyl)-glycine (L-CCG III) and (2S,4R)-4-methylglutamate. In contrast, L-anti,endo-3,4-methanopyrrolidine dicarboxylate (L-a,e-MPDC) was about an order of magnitude less potent. Only subtle regional variations in the characteristics of inhibitors of [3H]L-aspartate binding were detected. It is not certain whether these differences reflect regional variations in the distribution of individual glutamate transporters or regional peculiarities in their pharmacological characteristics. In particular, (2S,4R)-4-methylglutamate, shown previously to differentiate between GLT-1 (principal glutamate transporter in the forebrain) and GLAST (expressed mainly in the cerebellum), did not strongly differentiate between the binding of [3H]L-aspartate in forebrain and cerebellum. Computer-assisted molecular modelling using selected glutamate analogues with restricted conformation (L-trans-pyrrolidine-2,4-dicarboxylate and four isomers of 2-(carboxycyclopropyl)-glycine: L- and D-CCG I, L-CCG III and L-CCG IV) identified at least one area of unfavourable steric interaction. We conclude that the quantitative autoradiographic studies using [3H]L-aspartate or other transporter-specific ligands, will be a useful tool to study the pharmacology of substrate binding sites on glutamate transporters in the mammalian brain in situ.

Surgical treatment of severe hindfoot valgus by medial displacement osteotomy of the os calcis in children with myelomeningocele

This is a retrospective review of 27 patients with severe hindfoot valgus who were treated with a medial sliding osteotomy of the os calcis. The group consisted of 38 feet in 27 patients with myelomeningocele, ranging in age from 7 to 17 years. Follow-up averaged >5 years. The amount of hindfoot deformity, problems with brace and shoe wear, and overall patient satisfaction were analyzed. Eighty-two percent of the patients were completely satisfied. Most had complete correction of the hindfoot deformity. There was one superficial pin site infection and no nonunions.

An investigation on the ecology of Triatoma vitticeps (Stal, 1859) and its possible role in the transmission of Trypanosoma cruzi, in the locality of Triunfo, Santa Maria Madalena municipal district, state of Rio de Janeiro, Brazil

From January 1989 to April 1995, 465 specimens of Triatoma vitticeps were collected in the locality of Triunfo, 2nd District of Santa Maria Madalena municipal district, State of Rio de Janeiro. The bugs were found indoors by local residents with predominance of adults. The flight activity was high in hot months when the incidence in the domicile also increased. Two hundred and two bugs (111 alive and 91 dead) were examined for Trypanosoma cruzi infection. This was detected in 31 of the dead bugs (34%) and 88 (79%) of the live bugs examined. With a view to investigate the possible vertebrate hosts of the T. cruzi isolates, the blood of 122 mammals was examined through Giemsa-stained smears, hemocultures and xenodiagnosis. T. cruzi was detected in three specimens of Didelphis marsupialis and T. (M.) theileri was detected in one specimen of Bos taurus. The parasites were isolated from triatomine feces, xenoculture and hemoculture. No evidence of human infection was detected in 58 inhabitants examined, as evaluated by indirect imunofluorescence technique using T. cruzi epimastigotes as antigens. These results show that T. vitticeps is still a sylvatic species although nymphs have been found inside the domicile. Thus, an epidemiological vigilance is necessary to know the behaviour of this species following the continuous modifications promoted by the presence of man.

Effect of post-mortem delay on density of tachykinin receptors in rat peripheral tissues

The effect of post-mortem delay on the affinity and density of tachykinin NK1 and NK2 receptors was examined in the rat submandibular gland and gastric fundus, respectively, using saturation binding studies with the radioligands [125I]Bolton-Hunter [Sar9, Met(O2)11]SP and [125I][Lys5, Tyr(I2)7, MeLeu9, Nle10]NKA(4-10). For NK1 receptors, no significant changes were seen in either Kd (control 375 +/- 35 pM, n = 5; 32 h post-mortem 390 +/- 59 pM, n = 5) or Bmax (control 96 +/- 16 fmol/mg protein, n = 5; 32 h post-mortem 62 +/- 10 fmol/mg protein, n = 5). For NK2 receptors, no alterations were seen up to 16 h post-mortem. However, significant (p < 0.001) changes were seen at 32 h post-mortem (n = 4), where values for Kd were increased (3.0 +/- 0.2 nM) and those for Bmax were reduced (42 +/- 5.9 fmol/mg protein), relative to control (Kd = 1.3 +/- 0.2 nM; Bmax = 208 +/- 30 fmol/mg protein, n = 5). These changes are probably related to observed histological deterioration. This study demonstrates the stability of tachykinin receptors in these peripheral tissues and indicates the suitability of post-mortem tissue as a valid control in future tachykinin receptor studies.

P2 purinoceptor blocker suramin antagonises NMDA receptors and protects against excitatory behaviour caused by NMDA receptor agonist (RS)-(tetrazol-5-yl)-glycine in rats

It has been reported that suramin, an anthelminthic, trypanocidal agent and an inhibitor of P2 receptors, may antagonise N-methyl-D-aspartate (NMDA) subtype of the excitatory amino acid receptors. Both NMDA receptors and P2X subclass of P2 receptors are ligand-gated Ca2+-selective channels and, since the increased influx of Ca2+ into neurons has been linked to neurotoxicity, simultaneous inhibition of P2X and NMDA receptors in vivo by suramin could represent an effective neuroprotective treatment. We have found that suramin inhibited the binding of [3H]CGP 39653 to NMDA receptor binding sites in vitro and reduced the frequency of NMDA channel openings in patch-clamp studies. Suramin (1 mM) had no effect on [3H]kainate binding in vitro. In vivo, intracerebroventricular (I.C.V.) injections of suramin (70 nmol/brain) antagonised convulsive effects of the NMDA agonist (RS)-(tetrazol-5-yl)-glycine (TZG, LY 285265). Suramin, however, did not prevent neurotoxic lesions in the hippocampus caused by I.C.V. administration of TZG. Increasing the dose of suramin resulted in death from severe respiratory depression.

Gait electromyography in children with myelomeningocele at the sacral level

OBJECTIVE

Patients with sacral level myelomeningocele can be expected to maintain a high level of ambulatory status long into adulthood. Gait deterioration and knee pain reported in this population may be attributed to compensatory movements and increased recruitment of less affected muscle groups to achieve this desired level of ambulation. The objective of this study was to analyze the effect of the solid ankle-foot-orthoses (AFOs) on the muscular activity of selected muscles during walking.

DESIGN

Cohort/outcome.

SETTING

Laboratory.

PATIENTS

Twenty four patients with sacral level myelomeningocele between 4 to 17 years of age.

INTERVENTION

Electromyographic activity of selected muscle groups were studied during barefoot walking and walking with solid AFOs at a self-selected walking velocity.

MAIN OUTCOME MEASURES

Timing of electromyographic activity and sagittal plane knee kinematics. Comparison to normal electromyographic patterns and changes between barefoot and AFO walking conditions.

RESULTS

With the AFOs there was significantly less prolonged stance phase quadriceps activity compared with barefoot walking, although greater than normal activity persisted. There was no change between conditions for the other monitored muscle groups. All muscles elicited greater duration of activity over the course of the gait cycle.

CONCLUSIONS

Our results show that solid AFOs improve the prolonged knee extensor activity evident for barefoot walking. This is clinically relevant to the gait deterioration and knee pain sometimes seen in this patient population. We espouse early and persistent orthotic intervention to reduce compensatory muscular overactivity and maintain gait quality.

The prognostic value and significance of serial bone scintigraphy in Legg-Calvé-Perthes disease

We reviewed 44 consecutive patients treated for Legg-Calvé-Perthes disease who underwent serial technetium 99m diphosphonate bone scintigraphy. The average follow-up was 4.4 years. The bone-scintigraphy classification characterizes the A pathway by early lateral column formation not seen in the B pathway. Pathway A had 20 hips. The average age at presentation was 6.1 years. At last follow-up, this group had an average Mose classification of 1.2 and Catterall score of 2.4, without any patient having "head-at-risk" signs or requiring operative treatment. Pathway B had 20 hips. The average age at presentation was 5.8 years. At last follow-up, this group had an average Mose classification of 5.2, a Catterall score of 3.5, and 18 patients had head-at-risk signs, with 11 requiring operative treatment. Our bone-scintigraphy classification preceded the radiographic head-at-risk signs by an average of 3 months, allowing earlier treatment and correlated with subsequent femoral head involvement.

Congenital talipes equinovarus in spina bifida: treatment and results

The results of the surgical treatment of clubfoot deformity in spina bifida by radical posteromedial-lateral release (PMLR) are presented. In all cases, the Cincinnati incision was used and the tendons excised, including the anterior tibial tendon. In 21 feet, a special K-wire was used to derotate the talus in the ankle mortise. The minimum follow-up was 2 years. The average age at surgery was 14 months. The overall results showed 63% good, 14% fair, and 23% poor results. In the 21 feet in which the talus K-wire was used, 76% had a good result, 14% fair, and 10% poor. The results were also analyzed based on the motor level. In the thoracic/high lumbar level, 50% had a poor result. In the low lumbar and sacral level groups together, of 45 feet, five had a poor result. This study shows that a radical PMLR can produce an overall good and fair result in 77% of the cases. The use of the K-wire to derotate the talus led to an improvement in the result. The tendon excision leading to a flail foot corrects any residual muscle imbalance. The poor results seen in the thoracic/high lumbar patients are likely to be related to the lack of weight bearing in view of their motor paralysis.

Autoradiographic studies indicate regional variations in the characteristics of L-glutamate transporters in the rat brain

Quantitative autoradiography of [3H]L-aspartate binding in thaw-mounted sections of rat brain has shown that L-trans-pyrrolidine-2,4-dicarboxylate and D-threo-3-hydroxyaspartate but not DL-2 aminoadipate strongly interacted with the binding sites while dihydrokainate, kainate and beta-aminoadipate produced only weak effects. The potency of inhibitors did not vary from one region to another in the telencephalon (neocortex, hippocampus and neostriatum) but, D-threo-3-hydroxyaspartate, L-trans-pyrrolidine-2,4-dicarboxylate, kainate and dihydrokainate inhibited [3H]L-aspartate binding in the cerebellar cortex less potently than that in the forebrain. Characteristics of the known excitatory amino acid transporters can, in part, explain the present results but contributions from additional transporter molecules to the heterogeneity of [3H]L-aspartate binding sites cannot be ruled out.

Inhibition of [3H]CGP 39653 binding to NMDA receptors by a P2 antagonist, suramin

Suramin, which has been used for more than 50 years as an anthelmintic in humans, has recently been shown to inhibit P2 purinoceptors in the CNS and to block glutamate-evoked excitatory potentials in hippocampus. We now report that suramin inhibits (IC50 approximately 100 microM) the binding of [3H]CGP 39653, a ligand specific for NMDA-type glutamate receptors in brain. Consequently, suramin at concentrations used sometimes in physiological experiments may act as both P2x and NMDA antagonist. Since both NMDA receptors and P2x-subtype of purinoceptors form Ca(2+)-selective channels, suramin may block Ca2+ entry into neurones depolarized by either ATP, L-glutamate or any other neurotransmitter or drug acting via P2x or NMDA receptors.

Selective posterior rhizotomy and soft-tissue procedures for the treatment of cerebral diplegia

The results of selective posterior rhizotomy in fifty patients (group I) and of soft-tissue procedures in fifty patients (group II), all 100 of whom had cerebral diplegia and were seen in a private office, were reviewed retrospectively. No effort was made to randomize the treatment, as the selection criteria for the two procedures are different. We evaluated the range of motion and the ability and quality of walking preoperatively and postoperatively as well as the need for additional operative intervention in the two groups. The average age of the patients in both groups was five years (range, three to twelve years in group I and one to thirteen years in group II). The average duration of follow-up in both groups was four years (range, one to six years in group I and one to seven years in group II). Thirty-two patients (64 percent) in group I and forty-one patients (82 percent) in group II were able to walk independently at the latest follow-up examination. Both groups had an over-all improvement in the ranges of abduction of the hips and dorsiflexion of the ankles, a decrease in the flexion contractures of the hips, and more normal popliteal angles; however, with the numbers available, there were no significant differences in these measurements between the two groups at the 0.05 percent confidence level. Despite the overall improvement in range of motion, thirty-one patients in the rhizotomy group subsequently had soft-tissue releases, and twenty-two patients in the soft-tissue-release group had additional operative intervention.

Walking ability in spina bifida patients: a model for predicting future ambulatory status based on sitting balance and motor level

Two-hundred six patients with spina bifida were followed from birth to an average age of 115 months. We characterized the population in terms of factors which we expected to affect walking ability. Two independent predictors of community ambulation were identified through regression analysis: sitting balance and motor level. We used these variables to develop a mathematical method to predict which groups were likely to be independent walkers into adolescence. When we tested this equation against our actual population, we correctly characterized walkers as such in 92% of the cases. Furthermore, when we applied this equation to another random population taken from our clinic, we successfully characterized walkers in 92% of the cases. The strength of these observations allows us to provide guidelines to parents about the likelihood of their children being able to walk independently as adolescents on the basis of motor level and sitting balance, which can be assessed at an early age.

A convective-diffusion model for dissolution of two non-interacting drug mixtures from co-compressed slabs under laminar hydrodynamic conditions

A numerical convective-diffusion dissolution model has been extended to describe dissolution of two neutral non-interacting drugs co-compressed in a slab geometry. The model predicted the experimental dissolution rates of naproxen/phenytoin mixtures and hydrocortisone/nitrofurantoin mixtures quite accurately, except for phenytoin in the naproxen/phenytoin mixture at low weight proportions. A non-linear dependence of dissolution rate on weight proportion with a positive deviation from linearity was observed. An increase in flow rate increased the dissolution rate and the cube-root dependency of dissolution rate on the flow rate for a given weight proportion of the component in the slab, as proposed earlier by Shah and Nelson for pure compounds, was also observed here, suggesting that the changes in dissolution profile were caused by changes in surface area only. As expected from the model an increase in particle size of the powders used to make the slab decreased the dissolution rate. This was explained by an increase in the average length of the component resulting in a bigger 'carryover' of material from one section of the component in the slab to the next section of the same component, due to convection, and hence lower flux.

Arterial and venous compromise by an osteochondroma

A 9.5-year-old girl had popliteal arterial and venous compression by a distal femoral osteochondroma. Magnetic resonance imaging demonstrated the relation of the vessels to the osteochondroma and a three-phase bone scintigram showed asymmetry of arterial perfusion and evidence of venous stasis.

Developmental hip dysplasia potentiated by inappropriate use of the Pavlik harness

Nineteen patients with 28 dislocated hips treated in a Pavlik harness for > 8 weeks with no evidence of hip reduction were identified. After discontinuation of the harness use, reduction was often difficult to obtain and maintain. Thirteen of these patients (17 hips) required operative intervention to obtain stable located hips. In this group of patients, we attempted to identify factors that led to an unusually high number of failures of closed management techniques. Prolonged positioning of the dislocated hip in flexion and abduction potentiates dysplasia, particularly of the posterolateral acetabulum, and increases the difficulty of obtaining a stable closed reduction. Confirmation of satisfactory reduction during treatment with the Pavlik harness is mandatory. Such treatment should be discontinued promptly if reduction is unobtainable.

Congenital and acquired orthopedic abnormalities in patients with myelomeningocele

This article presents a radiologic review of the spectrum of acquired and congenital orthopedic abnormalities found in patients with myelomeningocele. These abnormalities are caused predominantly by muscle imbalance, paralysis, and decreased sensation in the lower extremity. Iatrogenic injury, such as a postoperative tethered cord, may also cause bone abnormalities. Selected images were obtained from more than 800 children. Important entities presented include spinal curvatures such as kyphosis, scoliosis, and lordosis; subluxation and dislocation of the hip, coxa valga, contractures of the hip, and femoral torsion; knee deformities; rotational abnormalities of the lower extremity and external and internal torsion; ankle and foot abnormalities such as ankle valgus, calcaneus foot, congenital vertical talus (rocker-bottom deformity), and talipes equinovarus; and metaphyseal, diaphyseal, and physeal fractures. Familiarity with congenital abnormalities and an understanding of the pathogenesis of acquired disorders in patients with myelomeningocele are essential for proper radiologic interpretation and timely therapy.

Calcaneus deformity in spina bifida: results of anterolateral release

We reviewed a group of patients with 76 feet treated operatively for a calcaneus or a calcaneovalgus deformity by a simple anterior (tenotomy of the tibialis anterior, extensor digitorum communis and extensor hallucis longus), or anterolateral (associated tenotomy of the peroneus longus and brevis) release. The results were assessed considering bracing and shoewear problems or presence of pressure sores. The mean follow-up time was 4.66 years, and a good result was achieved in 62 feet (81.5%), with 14 poor results in 18.5%. Among the 14 poor results, six deformities have recurred and were operatively treated by the same technique and eight feet developed an equinus deformity requiring a heel cord release.

The natural history of congenital kyphosis in myelomeningocele. A review of 51 children

The progression of congenital lumbar kyphosis in myelomeningocele is a well-known problem, but rates of progression are not well documented in the literature. Fifty-one children with congenital kyphosis and myelomeningocele were followed for an average of 4.8 years. Minimum follow-up was 1 year. Group I (35 patients) had initial radiographs at 1 year of age or less. Group II (16 patients) had radiographs taken after the age of 1 year. Curves less than or equal to 90 degrees in Group I progressed 7.7 degrees/yr; those greater than 90 degrees progressed 12.1 degrees/yr. Curves less than or equal to 90 degrees and greater than 90 degrees progressed at similar rates, regardless of initial curve magnitude: 6.4 degrees/yr and 6.7 degrees/yr, respectively. No correlation existed among the rate of curve progression, the frequency of shunt revisions, or the presence of vertebral anomalies, aside from the dysraphism.

Musculoskeletal problems in association with cloacal exstrophy

The records of all thirteen patients for whom a diagnosis of cloacal exstrophy had been recorded in our hospitals were analyzed for evidence of musculoskeletal problems. All thirteen patients had spina bifida, four had congenital scoliosis, two had congenital kyphosis, and three had non-congenital scoliosis. All had a lipomeningocele, and eleven had paralysis of the lower extremities. Hydrocephalus and its associated problems were not found, but tethered-cord syndrome was diagnosed in eleven patients. Persistent diastasis of the symphysis pubis was found in all patients. Abduction and external rotation of the hips were more than normal. Mild dysplasia was seen in six of the twenty-six hips. Deformities of the foot were common, and twelve feet had been operated on for correction. Recurrent equinovarus deformity of the foot was associated with tethered-cord syndrome in two patients.

Talectomy in the treatment of resistant talipes equinovarus deformity in myelomeningocele and arthrogryposis

Eighteen patients (28 feet) with spina bifida and arthrogryposis had talectomy for correction of severe equinovarus deformity. In 26 feet, posteromedial release had been performed previously. The average age at surgery was 4 1/2 years, with a range of 1-9 years of age. The length of follow-up averaged 4 years and ranged from 12 months to 8 years. Twenty-three feet were rated good, and five were poor. Six feet, because of forefoot adduction, required further surgery (metatarsal osteotomy). Talectomy is an effective procedure for correction of hindfoot deformity. Forefoot problems must be treated as a separate entity.

Scintigraphic localization of bone lesions during surgery

Nuclear medicine provides several methods for increasing the accuracy of surgical removal of bone lesions with focally increased uptake. In this paper, three intraoperative procedures are discussed: remote control by imaging, intraoperative control by imaging, and intraoperative control by scintillation probe. All techniques require preoperative injection of bone imaging tracer. Remote operative control calls for a gamma camera to mark the skin over the lesion prior to surgery, providing optimal preoperative localization and imaging of the excised lesion to ensure complete removal. Intraoperative control procedures require that a portable camera or a scintillation probe be used in the operating room; these permit direct monitoring of localization and resection. Our experience with 18 procedures performed on 15 patients suggests that these techniques are worthy of continued use.

Valgus deformity of the ankle joint: pathogenesis of fibular shortening

An abnormal shortening of the fibula, leading to a valgus deformity of the ankle joint, is a common finding in the paralytic ankle. This article analyzes 173 ankles in which shortened fibulae were present. Analysis of several factors that interfere with fibular growth showed that soleus strength and anatomical continuity of the fibula are important factors in the normal fibular growth. Any factor that interferes with the normal balance of forces at the distal fibula physis can cause an abnormal shortening of the fibula and lead to valgus deformity of the ankle.

The role of computed tomography and radionuclide scintigraphy in the localization of osteomyelitis in flat bones

The combined use of radionuclide scintigraphy and computed tomography is recommended for evaluating children with laboratory and clinical data suggestive of flat bone osteomyelitis despite normal conventional radiographs. In addition, computed tomography may be helpful in the presence of abnormal radiographs in determining the exact location of the focus of osteomyelitis and the most suitable route for appropriate drainage or to obtain culture material.

Evaluation of tarsal coalition by computed tomography

Three cases of talocalcaneal and two calcaneonavicular tarsal coalitions were evaluated with plain radiography and computed tomography (CT). Four of five of the patients' plain films were read as normal. Two of three patients had a Harris view performed for the talocalcaneal middle facet coalitions. One was read as negative, the second as positive after five attempts at obtaining the correct angle. In addition, two of three patients with talocalcaneal middle facet coalition had conventional tomography. One was read as positive, the other as negative. Arthrography was done in one case of calcaneonavicular coalition and was suspicious for the coalition. CT was diagnostic in all five cases. It provided an accurate depiction of the coalition site. In addition, the width of the bony bar at the coalition site could be determined to help plan surgical treatment. In patients presenting with painful feet, in whom tarsal coalition is suspected, plain radiographs should be the initial screening procedure. If secondary signs are present, CT is recommended as the best imaging modality to investigate further for tarsal coalition. Also, if plain films are normal but the index of suspicion is high, CT is thought to be the next most valuable test for diagnosing tarsal coalition.

Femoral neck abnormalities in spina bifida

Femoral neck abnormalities in spina bifida can be of two types: Type A, consisting of widening of the physis and often associated with varus deformity, and Type B, characterized by marked narrowing of the femoral neck, resulting in a typical mushroom appearance. The Type A deformity is usually associated with an abduction contracture of the hip. This physeal lysis seems to be secondary to microtrauma sustained during persistent exercise done by the parents and therapist to overcome the abduction contracture. No treatment is required, even when varus deformity is present. These patients require an orthosis with a pelvic band for ambulation, and their mobility will not be affected by the deformity.

Rotational deformities of the lower limb in myelomeningocele. Evaluation and treatment

We studied the results of surgical treatment for rotational deformities of the lower extremity in fifty children. The preoperative rotational deformities were subdivided as follows: (1) external rotation deformity of the hip (nine hips), (2) external tibial torsion (twenty-nine limbs), and (3) toeing-in gait (thirty-one limbs). These were further analyzed as to imbalance between the forces of the medial and lateral hamstrings, that imbalance associated with fixed internal tibial torsion, and isolated internal tibial torsion. The average length of follow-up was four years and six months. For the external rotation deformity of the hip we performed a derotation osteotomy with internal fixation at the subtrochanteric level. That procedure led to eight good results and one fair result. The external tibial torsion was treated by a derotation osteotomy of the tibia and fibula distally, with correction of the valgus deformity of the ankle if that was more than 10 degrees. In twenty patients a good result was obtained. For the toeing-in gait associated with a medial-lateral hamstring imbalance, the semitendinosus was transferred to the biceps and the head of the fibula. Good results were seen in ten of the fourteen patients. In twelve limbs a derotation osteotomy of the distal ends of the tibia and fibula was done alone, with eight good and fair results. In five patients a simultaneous semitendinosus transfer and derotation osteotomy was used. All had a good result. The over-all rate of good and fair results in the entire series was 79.6 per cent.

Computed tomography in the evaluation of the gluteal region

The role of computed tomography (CT) in the evaluation of the gluteal region was assessed. Six cases of gluteal masses were studied preoperatively by CT; several were also studied with conventional radiographic methods, including barium enema, cystogram, and intravenous urogram. Our case material included an epithelioid sarcoma, Ewing's sarcoma, endodermal sinus tumor, cystic hygroma, neurofibromatosis, and a normal variant. The conventional radiologic studies were normal or demonstrated nonspecific soft tissue density mass effect. By comparison, CT, with its cross-sectional imaging capability, provided unique diagnostic information. CT depicted the presence and origin of a mass, provided tissue characterization, and showed the extent of the lesion, often demonstrating the gluteal mass as an extension of an intrapelvic lesion. CT was valuable in monitoring tumor response to therapy, detecting recurrences, and excluding normal variants as the cause for a gluteal mass. The information provided by CT was important in treatment planning.

Fractures of the distal tibial epiphysis in adolescence

We studied the cases of nine adolescent patients with a Salter-Harris Type-III fracture of the lateral portion of the distal tibial epiphysis (sometimes called the juvenile Tillaux fracture) and eight patients with a triplane fracture of the distal tibial epiphysis. The mechanism of both injuries was postulated to be external rotation of the foot on the leg. There were both two-fragment and three-fragment triplane fractures in the series. The three-fragment triplane fractures occurred in younger patients, and surgical treatment was more frequently administered. The pattern of closure of the distal tibial growth plate in the adolescent strongly influenced the type of fracture.

Hip CT in congenital dislocation: appearance of tight iliopsoas tendon and pulvinar hypertrophy

The iliopsoas tendon can interpose between the femoral head and the acetabulum, preventing reduction or stability of reduction of a dislocated hip by a closed method. The tendon produces an infolding of the capsule and labrum. This infolding of the capsule and labrum creates an "isthmus" between the capital and the acetabular parts of the capsule. This deformity of the capsule was recognizable on computed tomography (CT) in 10 patients, all of whom had surgical confirmation of the findings. The presence of hypertrophied pulvinar can also be recognized by CT.

Surgical management of knee contractures in myelomeningocele

Contractures of the knee joint can interfere with orthotic fitting and prevent the child from being upright and ambulatory. Two types of knee contractures are seen: flexion and extension. A flexion deformity is more common in the thoracolumbar level and, when beyond 20 degrees, will require surgical treatment. The author reviewed his surgical experience with 23 knees undergoing a radical flexor release. With an average follow-up of 38 months, 10 knees showed no contractures, 11 knees 5 to 10 degrees of flexion deformity, and 1 knee a 15 degrees deformity. Three knees had a simple tendon release with poor results. Fifteen knees with an extension contracture were treated surgically (VY quadriceps lengthening). With a follow-up of 43 months, eight knees had 120 degrees of flexion, five 90 degrees, and two only 45 degrees. Three knees showed full recovery of quadriceps strength. It is concluded that a knee flexion deformity will respond well to the radical flexor release. Prolonged splinting is important in order to avoid recurrence. An extension contracture can be successfully treated by the VY quadriceps plasty with improvement in the child's gait and sitting.