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ABSTRACT: Both congenital and acquired orthopaedic deformities are common in patients with spina bifida. Examples of congenital deformities, which are present at birth, include clubfoot and vertical talus. Acquired developmental deformities are related to the level of neurologic involvement and include calcaneus and cavovarus. Orthopaedic deformities may also result from postoperative tethered cord syndrome. The previously published Part I reviewed the overall orthopaedic care of a patient with spina bifida, with a focused review of hip, knee, and rotational deformities. This paper will cover foot and ankle deformities associated with spina bifida, including clubfoot, equinus, vertical talus, calcaneus and calcaneovalgus, ankle and hindfoot valgus, and cavovarus. In addition, this paper will address the issues surrounding skin breakdown in patients with spina bifida.
Journal of Children s Orthopaedics 12/2011; 5(6):403-14.
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ABSTRACT: Posterior wall acetabular fractures are rare in the pediatric patient but require proper management to prevent significant complications. Plain radiographs and computed tomography scans are standard diagnostic imaging used with clinical examination of hip stability to determine if the injury requires open reduction and internal fixation. Two cases are presented of adolescent traumatic hip dislocations and posterior wall fractures in which radiography underestimated the extent of the posterior wall fracture. In one case, a magnetic resonance imaging study more clearly characterized the injury. Because the ossification of the posterior wall occurs throughout adolescence, magnetic resonance imaging may be a useful tool in characterizing these fractures and assisting with surgical planning.
Journal of orthopaedic trauma 07/2011; 25(7):e68-73. · 1.78 Impact Factor
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ABSTRACT: Knee flexion contracture leading to crouch gait is commonly seen in children with myelomeningocele. Progressive increase in knee flexion contracture increases energy cost, which interferes with efficient, functional ambulation. To prevent this, surgical release has been recommended when a knee flexion contracture exceeds 15° to 20°.
We therefore asked whether knee flexion contracture release improved dynamic sagittal motion and walking velocity using computerized gait analysis.
We retrospectively studied 11 patients (20 knees) with high-sacral-level or low-lumbar-level myelomeningocele and knee flexion contracture of greater than 15°. All patients underwent dynamic gait analysis pre- and postoperatively. Surgery consisted of selective hamstring lengthening (medial and lateral), gastrocnemius release from the femoral condyles, and posterior knee capsulectomy.
We observed improvements postoperatively in clinical measurements and sagittal kinematics. The clinical knee flexion contracture improved from a mean of 24.9° preoperatively to 5.9° postoperatively. The knee flexion at initial contact improved from 37.6° to 9.0°, and minimum knee flexion in single-leg stance improved from 48.2° to 16.4. Walking velocity improved from 72.2% to 80.0% of age-matched normal.
Surgical treatment of knee flexion contracture in patients with myelomeningocele using radical posterior knee capsulectomy leads to improvement in clinical knee flexion contracture, dynamic sagittal kinematics, and walking velocity.
Clinical Orthopaedics and Related Research 12/2010; 469(5):1286-90. · 2.53 Impact Factor
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ABSTRACT: The aim of this paper was to review the outcomes of treatment of dislocated but reducible (Ortolani-positive) hips.
A comparative retrospective review was conducted of all patients aged younger than 6 months who presented for treatment of developmental dysplasia of the hip for two 10-year periods. The inclusion criteria consisted of a clinical evaluation documenting Ortolani-positive examination, no previous treatment, and an initial treatment with Pavlik harness only. Patients with insufficient follow-up, neuromuscular disease, provocative dislocatable hips, or dislocated but not reducible hips were excluded. In group 1 (1984-1994), treatment involved initiation of Pavlik harness and parental education at the time of initial diagnosis. Group 2 (1997-2007) was treated the same as group 1 with the addition of serial orthopaedic office-based ultrasound examinations and use of a hip abduction orthosis in hips remaining unstable after 3 weeks in the Pavlik harness. Records were assessed for successful achievement and maintenance of hip reduction, need for and type of further treatment, and development of avascular necrosis.
In group 1, the mean time of follow-up was 28 months. Forty-four (85%) of 52 hips were treated successfully. Eight patients required further operative treatment. In group 2, the mean follow-up to the final evaluation was 34 months. Forty-one (93%) of 44 hips were treated successfully. Three hips required further treatment. There were no documented cases of avascular necrosis in patients treated for orthoses only in either group.
In 1994, we presented a series of 52 Ortolani-positive hips (group 1) with a success rate of reduction of 85%. Now, our protocol for treating Ortolani-positive hips has evolved to include serial orthopaedic office-based ultrasound in all patients and use of a hip abduction orthosis in hips remaining unstable after 3 weeks in a Pavlik harness. Three previous studies at major centers reported successful reduction in only 63% to 71%. In group 2, our current success rate of 93% exceeds that previously reported by us and is significantly greater than these 3 previous studies (all P < 0.006). Furthermore, our current treatment module has decreased our rate of open reduction from 10% in group 1 to 5% in group 2. LEVEL OF RELEVANCE: Therapeutic study, level 3.
Journal of pediatric orthopedics 29(3):224-30. · 1.23 Impact Factor
