[Modified gluteus maximus transfer for hip abductor deficiency]. / Modifizierter Gluteus-maximus-Transfer zur Therapie der glutealen Insuffizienz.

OBJECTIVE: Transfer of the gluteus maximus with refixation at the greater trochanter for treatment of abductor deficiency. INDICATIONS: Symptomatic abductor deficiency with atrophy and fatty degeneration of the gluteal muscles > 50% (grade 3 by quartile) with good strength of the gluteus maximus. CONTRAINDICATIONS: Low atrophy or fatty degeneration of less than 50% of the gluteal muscles, limited strength of the gluteus maximus, infection. SURGICAL TECHNIQUE: First, the fascia lata is incised dorsally to the tensor fascia latae muscle, with the incision extending approximately 1.5 cm proximal to the iliac crest. A second incision divides the gluteus maximus muscle longitudinally along the muscle fibers and continues towards the fascia lata distal to the greater trochanter. These incisions result in a triangular muscle flap, which is elevated and divided into anterior and posterior portions. The posterior flap is positioned ventrally over the femoral neck and fixed to the anterior capsule and the anterior edge of the greater trochanter. The anterior flap is placed directly on the proximal femur. For this purpose, a groove is prepared in the area of the proximal femur using a spherical burr to freshen up the future footprint. The anterior flap is positioned from the tip of the greater trochanter towards the insertion of the vastus lateralis muscle. Subsequently, the anterior flap is fixed to the created groove with transosseous sutures and positioned under the elevated vastus lateralis muscle in 15° abduction of the leg. To provide additional stabilization to the tendinous part of the anterior flap, a screw is inserted distally to the greater trochanter. The vastus lateralis muscle is attached to the distal tip of the anterior flap, and the remaining gluteus maximus muscle is sutured to the fascia lata to cover the anterior flap. Additionally, a flap of the tensor fascia latae muscle can be mobilized and adapted to the reconstruction. Layered wound closure is performed. RESULTS: The technique of a gluteus maximus transfer represents a method for the treatment of chronic abductor deficiencies and improves abduction function as well as the gait pattern in short-term follow-ups. Fifteen patients (mean age at time of surgery 62 years) had after a mean follow-up of 2.5 years. The modified Harris Hip Score (mHHS) improved from 48 points preoperatively to 60 points at follow-up. Preoperatively, 100% had a positive Trendelenburg sign; at follow-up, this was about 50%.

Severe rigid hip flexion-abduction contracture in cerebral palsy: a case report and review of the literature.

INTRODUCTION: severe, rigid hip abduction deformity in individuals with cerebral palsy (CP) is an exceptionally uncommon condition. This posture hinders the positioning in the wheelchair and the completion of basic activities of daily living (ADL). Addressing such severe deformities can be quite challenging. MATERIAL AND METHODS: a 14-year-old male, with spastic-dystonic quadriplegic CP, developed rigid and severe flexion-abduction contractures in both hips, characterized by 90 degrees of flexion and 100 degrees of abduction. These contractures severely impeded his ability to comfortably use a wheelchair and even pass through doorways. Performing basic ADLs became a significant challenge for both the patient and his caregivers. RESULTS: the treatment approach involved a two-stage surgical procedure, one for each hip, with a two-month interval between them. An extensive release of the fascia latae, gluteus maximus, external rotators, and hip flexors; in combination with a proximal femur osteotomy were performed. To maintain the corrections achieved, long-leg casts connected with two bars were employed, followed by orthotic support and physiotherapy. Following the procedure, lower limb adduction was achieved, and the patient and caregivers were highly satisfied, as ADLs and basic caregiving had been greatly facilitated. CONCLUSIONS: while the available literature on the management of severe rigid abduction hip contractures in non-ambulatory CP patients is limited, and treatment options are often complex, the present case underscores the effectiveness of a comprehensive approach involving soft tissue release and bone surgery. Achieving a more favorable wheelchair positioning and facilitating basic ADLs and care represents a significant success for patients and families.

INTRODUCCIÓN: la deformidad severa y rígida en abducción de cadera en individuos con parálisis cerebral (PC) es una condición infrecuente. Esta postura dificulta el posicionamiento en la silla de ruedas y la realización de actividades básicas de la vida diaria (AVD). El tratamiento de estas deformidades tan severas puede ser todo un reto. MATERIAL Y MÉTODOS: varón de 14 años, con PC tetrapléjica espástica-distónica, que desarrolló contracturas rígidas y severas de flexión-abducción en ambas caderas, caracterizadas por 90 grados de flexión y 100 grados de abducción. Estas contracturas impedían gravemente su capacidad para utilizar cómodamente una silla de ruedas e incluso pasar por las puertas. La realización de actividades básicas de la vida diaria se convirtió en un reto importante tanto para el paciente como para sus cuidadores. RESULTADOS: el tratamiento consistió en una intervención quirúrgica en dos fases, una para cada cadera, con un intervalo de dos meses entre ellas. Se realizó una amplia liberación de la fascia lata, el glúteo mayor, los rotadores externos y los flexores de la cadera; en combinación con una osteotomía proximal del fémur. Para mantener las correcciones conseguidas, se emplearon escayolas de pierna larga conectadas con dos barras, seguidas de soporte ortésico y fisioterapia. Tras la intervención, se consiguió la aducción de los miembros inferiores y el paciente y los cuidadores se mostraron muy satisfechos, ya que se habían facilitado en gran medida las AVD y los cuidados básicos. CONCLUSIONES: aunque la bibliografía disponible sobre el tratamiento de las contracturas rígidas graves de la cadera en abducción en pacientes no deambulantes con PC es limitada, y las opciones de tratamiento suelen ser complejas, el presente caso subraya la eficacia de un enfoque integral que incluye la liberación de los tejidos blandos y la cirugía ósea. Conseguir una posición más favorable en la silla de ruedas y facilitar las AVD básicas y los cuidados representa un éxito significativo para los pacientes y sus familias.

Sagittal alignment in patients with flexion contracture of the hip before and after total hip arthroplasty.

INTRODUCTION: In hip osteoarthritis, hip flexion contracture can severely alter the patient's alignment, and, therefore, affect the patient's quality of life (QOL). Hip contracture is not well-studied, partly because of the difficulties of its diagnosis. The aim of this study was to propose a quantitative definition of hip flexion contracture, and to analyse sagittal alignment in these patients compared to non-contracture ones, before and 12 months after total hip arthroplasty (THA). MATERIALS AND METHODS: Consecutive patients with hip arthrosis and an indication for THA were included (N = 123). Sagittal full-body radiographs were acquired in free standing position and in extension. QOL questionnaires were administered before and after surgery. Spinopelvic parameters were measured, including the pelvic-femur angle (PFA). Patients with low pelvic incidence (< 45°) were included in the hip contracture group if PFA > 5°, or PFA > -5° when pelvic incidence ≥ 45°. RESULTS: 29% of patients were in the hip flexion contracture group, and they showed lower pelvic tilt than the no-contracture group (p < 0.001), larger lumbar lordosis (LL) and smaller PI-LL (p < 0.001), as well as a forward position of the head. 16% of patients still had hip contracture 12-months postop. Contracture patients showed higher QOL scores after surgery. CONCLUSIONS: The proposed method to diagnose hip contracture group allowed to define a group of patients who showed a specific pattern of sagittal spinopelvic alignment. These patients improved their alignment and quality of life postoperatively, but their hip mobility was not always restored. Diagnosing these patients is a first step toward the development of more specific surgical approaches, aiming to improve their surgical outcome.

Hip Pain in Patients With Spinal Muscular Atrophy: Prevalence, Intensity, Interference, and Factors Associated With Moderate to Severe Pain.

BACKGROUND: A subset of patients with spinal muscular atrophy (SMA) develop hip pain. We analyzed (1) the characteristics of hip pain in patients with SMA (prevalence, intensity, interference with activities, and responsiveness to treatment) and (2) factors (patient, clinical, and radiographic) associated with moderate to severe pain. METHODS: We performed a retrospective record review and telephone survey of 104 patients with SMA (77% response rate; 44% female; mean age, 22±13 y) who presented for treatment between 2010 and 2020. Patient, clinical, and radiographic characteristics (when available) were recorded. Patients with current or past hip pain were asked about pain characteristics. Pain intensity and interference were assessed with the Brief Pain Inventory, modified for SMA (scale, 0 to 10 with 0 indicating no pain/interference). We used univariate analysis and ordered logistic regression to determine associations between patient factors and hip pain (α=0.05). RESULTS: Hip pain occurred in 60/104 patients (58%), with 15 (14%) indicating moderate to severe pain. Compared with patients with normal body mass index values, patients who were obese had 5.4 times the odds [95% confidence interval (CI), 1.3-23] of moderate to severe pain. Hip contractures [adjusted odds ratio (aOR), 3.2; 95% CI, 1.2-8.8] and dislocations (aOR, 2.9; 95% CI, 1.1-7.9) were associated with greater odds of pain compared with hips without these presentations. Surgical correction for scoliosis (aOR, 2.6; 95% CI, 1.1-6.5) was also associated with greater odds of moderate to severe pain. Femoral head migration percentage was the only radiographic parameter associated with pain. Mean modified Brief Pain Inventory pain intensity was 2.1±2.3. Prolonged sitting, sleep, and transfers (eg, bed to wheelchair) were the activities most affected by pain. CONCLUSIONS: Hip pain was moderate to severe in 14% of patients with SMA. Obesity, hip contractures, surgical correction of scoliosis, and hip dislocations were independently associated with pain. Although mean pain intensity was low, hip pain interfered with daily activities, including prolonged sitting, sleep, and transfers. LEVEL OF EVIDENCE: Level III.

Osseous Ilio-Trochanteric Bars as an Etiology of Hip Contracture in a Child with Congenital Contractures: A Case Report.

CASE: A 5-month-old female patient presented with bilateral lower-limb deformities. Hips were fixed at 100° abduction, 15° flexion and 45° external rotation, flexion contracture in the knees, and bilateral teratologic equinovarus deformities. Radiographs revealed ilio-trochanteric osseous bars as the etiology of hip contractures. Staged surgeries were undertaken. At 4 years of age, she could stand upright with orthoses and sit without support. CONCLUSION: This is the first study to report bilateral congenital ilio-trochanteric osseous bars, which were resected without recurrence. Even with a very low potential of walking, release of the contractures allows for better function and possible wheelchair-dependent mobility in the future.

Hip contractures were associated with low gross motor function in children with cerebral palsy.

AIM: The aim was to identify the prevalence of hip contractures and their association with gross motor function and pain in the lower extremities among Danish children with cerebral palsy (CP). METHODS: This cross-sectional study was based on data collected during regular clinical examinations in 2018-2019 and registered in the National Danish Clinical Quality Database of children with CP. The study population was 688 children (59% boys) aged five to 12 years across all Gross Motor Function Classification System (GMFCS) levels. Any associations between hip contracture and gross motor function and pain were investigated with logistic regression analysis and presented as odds ratios (OR) with 95% confidence intervals (95% CI). RESULTS: The prevalence of hip contracture was 22% across all five GMFCS levels, and the incidence varied across the five Danish regions. The odds ratios for hip contracture were significantly higher at GMFCS level IV (OR 1.99, 95% CI 1.10-3.62) and V (OR 5.49, 95% CI 3.33-9.07) compared with level I. Hip contractures were not significantly associated with pain in the lower extremities (OR 1.43, 95% CI 0.95-2.15). CONCLUSION: Hip contractures were frequent and associated with low gross motor function, but not lower extremity pain, in children with CP.

Spinopelvic Compensatory Mechanisms for Reduced Hip Motion (ROM) in the Setting of Hip Osteoarthritis.

STUDY DESIGN: Retrospective review from a single institution. OBJECTIVE: To investigate the effect of hip osteoarthritis (OA) on spinopelvic compensatory mechanisms as a result of reduced hip range of motion (ROM) between sitting and standing. SUMMARY OF BACKGROUND DATA: Hip OA results in reduced hip ROM and contracture, causing pain during postural changes. Hip flexion contracture is known to reduce the ability to compensate for spinal deformity while standing; however, the effects of postural spinal alignment change between sitting and standing is not well understood. METHODS: Sit-stand radiographs of patients without prior spinal fusion or hip prosthesis were evaluated. Hip OA was graded by Kellgren-Lawrence grades and divided into low-grade (LOA; grade 0-2) and severe (SOA; grade 3 or 4) groups. Radiographic parameters evaluated were pelvic incidence (PI), pelvic tilt (PT), lumbar lordosis (LL), PI-LL, thoracic kyphosis (TK), SVA, T1-pelvic angle (TPA), T10-L2, proximal femoral shaft angle (PFSA), and hip flexion (PT change-PFSA change). Changes in sit-stand parameters were compared between LOA and SOA groups. RESULTS: 548 patients were included (LOA = 311; SOA = 237). After propensity score matching for age, body mass index, and PI, 183 LOA and 183 SOA patients were analyzed. Standing analysis demonstrated that SOA had higher SVA (31.1 vs. 21.7), lower TK (-36.2 vs. -41.1), and larger PFSA (9.1 vs. 7.4) (all p < .05). Sitting analysis demonstrated that SOA had higher PT (29.7 vs. 23.3), higher PI-LL (21.6 vs. 12.4), less LL (31.7 vs. 41.6), less TK (-33.2 vs. -38.6), and greater TPA (27.9 vs. 22.5) (all p < .05). SOA had less hip ROM from standing to sitting versus LOA (71.5 vs. 81.6) (p < .05). Therefore, SOA had more change in PT (15.2 vs. 7.3), PI-LL (20.6 vs. 13.7), LL (-21.4 vs. -13.1), and T10-L2 (-4.9 vs. -1.1) (all p < .001), allowing the femurs to change position despite reduced hip ROM. SOA had greater TPA reduction (15.1 vs. 9.6) and less PFSA change (86.7 vs. 88.8) compared with LOA (both p < .001). CONCLUSIONS: Spinopelvic compensatory mechanisms are adapted for reduced hip joint motion associated with hip OA in standing and sitting. LEVEL OF EVIDENCE: Level III.

Two-Stage Treatment for Ankylosing Spondylitis With Severe Hip Contracture.

Ankylosing spondylitis is a progressive inflammatory disease that often involves the hip, causing deformities and dysfunction. Total hip arthroplasty (THA) may be used, but contracture of the hip joint in ankylosing spondylitis makes THA technically difficult and leads to poor efficacy. This retrospective study describes a novel 2-stage surgical treatment for ankylosing spondylitis of the hip and evaluates its efficacy relative to THA alone. Patients with ankylosing spondylitis and severe hip flexion contracture treated between 2011 and 2017 were assigned to either an experimental group or an age-matched control group (n=12 each) based on receiving, respectively, soft tissue release of the hip joint, femoral osteotomy, and supracondylar bone traction (stage I) and THA (stage II) or THA only. Clinical and radiological data included preoperative, postoperative, and follow-up Harris Hip Score and visual analog scale score, hip range of motion, femoral nerve injury, and heterotopic ossification. Both groups had significant corrections after surgery. At the final follow-up, the experimental group had significantly higher Harris Hip Scores and range of motion in extension compared with the control group, significantly more reduction in visual analog scale score, and no femoral nerve injury. The novel 2-stage surgery for patients with ankylosing spondylitis and severe hip flexion contracture is effective for restoring hip function and improving patients' quality of life, having fewer complications than traditional THA alone. [Orthopedics. 2019; 42(6):e502-e506.].

Histology and molecular pathology of iliotibial tract contracture in patients with gluteal muscle contracture.

The present study aimed to examine the pathologic changes of the iliotibial tract and discusses its relationship with gluteal muscle contracture. Samples of contractual iliotibial tracts were collected from six patients with contractures of the gluteal muscles and iliotibial tracts during their surgical treatment. Samples of normal iliotibial tracts were collected from six patients receiving surgeries for avascular necrosis of the femoral head who had no contractures of the gluteal muscles and iliotibial tracts. The tissue samples were stained using Hematoxylin and Eosin (H&E), Masson's trichrome, and Sirius Red. The mRNA and protein levels of various tissue repair genes were determined using quantitative real-time PCR and Western blotting. Both the normal and contractual iliotibial tracts consisted of type I and III collagens. The contractual iliotibial tracts had a significantly higher proportion of type III collagen in comparison with the normal iliotibial tracts. The mRNA expression levels and protein levels of tissue repair genes TGFß 1, bFGF, and matrix metalloproteinase-1 (MMP-1) in the contractual iliotibial tracts were up-regulated in comparison with that in the normal iliotibial tracts. However, the mRNA expression levels and protein levels of tissue inhibitors of metalloproteinase-1 (TIMP) in the contractual iliotibial tracts were down-regulated in comparison with that in the normal iliotibial tracts. The contractures of both the gluteal muscles and the iliotibial tracts share similar histology and molecular pathology. Our results indicate that iliotibial tract contracture is secondary to the gluteal muscle contracture and is a constant tissue repair process.

Gluteal Fibrosis and Its Surgical Treatment.

BACKGROUND: The objective of this study was to analyze the literature regarding the diagnosis, pathogenesis, and prevalence of gluteal fibrosis (GF) and the outcomes of treatment. METHODS: We searched PubMed, Embase, and Cochrane literature databases, from database inception to December 15, 2016. We used the following search terms including variants: "contracture," "fibrosis," "injections," "injections, adverse reactions,' "gluteal," and "hip." All titles and abstracts of potentially relevant studies were scanned to determine whether the subject matter was potentially related to GF, using predefined inclusion and exclusion criteria. If the abstract had subject matter involving GF, the paper was selected for review if full text was available. Only papers including ≥10 subjects who underwent surgical treatment were included in the systematic analysis. Data abstracted included the number of patients, patient age and sex, the type of surgical treatment, the method of outcome measurement, and outcomes and complications. RESULTS: The literature search yielded 2,512 titles. Of these, 82 had a focus on GF, with 50 papers meeting the inclusion criteria. Of the 50 papers reviewed, 18 addressed surgical outcomes. The surgical techniques in these papers included open, minimally invasive, and arthroscopic release and radiofrequency ablation. Of 3,733 operatively treated patients in 6 reports who were evaluated on the basis of the criteria of Liu et al., 83% were found to have excellent results. Few papers focused on the incidence, prevalence, and natural history of GF, precluding quantitative synthesis of the evidence in these domains. CONCLUSIONS: This study provided a systematic review of surgical outcomes and a summary of what has been reported on the prevalence, diagnosis, prognosis, and pathogenesis of GF. Although GF has been reported throughout the world, it requires further study to determine the exact etiology, pathogenesis, and appropriate treatment. Surgical outcomes appear satisfactory. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Postural asymmetry in non-ambulant adults with cerebral palsy: a scoping review.

PURPOSE: Non-ambulant adults with cerebral palsy are vulnerable to development of postural asymmetry and associated complications. The primary aim of this scoping review was to identify postural deformities in non-ambulant adults with cerebral palsy. MATERIALS AND METHODS: Comprehensive searches were undertaken in EMBASE, CINAHL, AMED, Cochrane, Psych INFO, and Joanna Briggs (1986-Jan 2017), supplemented by hand searching. Two reviewers independently extracted data using a customised tool focusing on study design, participant characteristics, postural descriptors, measurement tools, and interventions. RESULTS: From 2546 potential records, 17 studies were included. Variability in populations, reporting methodology, and measurement systems was evident. Data suggest more than 30% of this population have hip migration percentage in excess of 30%, more than 75% experience "scoliosis", and more than 40% demonstrate pelvic obliquity. Estimates ranged from 14% to 100% hip and 32% to 87% knee contracture incidence. Conservative interventions were infrequently and poorly described. CONCLUSION: Many non-ambulant adults with cerebral palsy experience postural asymmetry associated with windswept hips, scoliosis, pelvic obliquity, and limb contracture. Options for non-radiographic monitoring of postural asymmetry should be identified, and conservative interventions formally were evaluated in this population. Implications for rehabilitation The common postural asymmetries of windswept hips, scoliosis, pelvic obliquity, and limb contracture require standardised clinical measurement. Radiography is most commonly used to monitor postural asymmetry in this population, but standardised positioning is not applied and may not be feasible indicating a need for alternate methods and rigorous documentation. The Posture and Postural Ability Scale may be considered for use in the management of body shape in adults with CP.

Total Hip Arthroplasty in Ankylosing Spondylitis With Extension Contracture of Hips.

BACKGROUND: Despite significant pain relief following total hip arthroplasty (THA) in patients with ankylosing spondylitis, a small subset of patients presenting with extra-articular extension contracture of hips remains unsatisfied. METHODS: We retrospectively evaluated the patients with ankylosing spondylitis who underwent simultaneous bilateral THA and had extensor tightness of both hips preoperatively. They were managed with modified Z-plasty of iliotibial band. Patients with windswept deformity, commonly seen in bilateral hip arthritis caused by ankylosing spondylitis, were excluded. RESULTS: Between July 2011 and June 2015, out of 148 patients with bilateral hip involvement, 10 patients (20 hips) had extension contracture of both hips that was addressed during surgery. All patients were followed up for a minimum of 2 years. They could sit comfortably on a chair of height 18 inches with hips and knees flexed to at least 90°. The mean postoperative sum range of motion was 144.6° with an average hip flexion of 95° (range, 90°-105°). None of them had recurrence of extension contracture. There was significant improvement in range of motion and hence ambulation and function. No radiolucent lines exceeding 2 mm were seen in any of the zones around either of the components as evaluated in latest X-rays. CONCLUSION: Extension contracture of hip although rare is a noticeable problem and needs to be addressed during THA. Modified Z-plasty technique of iliotibial band is a reliable method in managing these patients.

Sustained hip flexion contracture after femoral lengthening in patients with achondroplasia.

BACKGROUND: Hip flexion contracture often occurs after femoral lengthening in patients with achondroplasia, but few studies have investigated its development in these patients. The purpose of this study was to analyze sustained hip flexion contracture in achondroplasia patients who underwent femoral lengthening and to identify contributing factors. METHODS: This study included 34 patients with achondroplasia who underwent femoral lengthening (mean age at operation, 11.1 years). Sustained hip flexion was defined as flexion contracture lasting > 6 months postoperatively despite physiotherapy. Demographic data, spinopelvic parameters (pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis, and sagittal vertical axis), and quantitative assessments of femoral lengthening were investigated. The associations among these factors and the development of sustained hip flexion contracture were assessed. RESULTS: Sustained hip flexion contracture developed in 13 (38%) of 34 achondroplasia patients after femoral lengthening. Eight (62%) of these 13 patients concomitantly exhibited limitation of knee flexion. Excessive femoral lengthening (odds ratio [OR], 1.450; 95% confidence interval [CI], 1.064 to 1.975; p = 0.019) and forward sagittal vertical axis tilt (OR, 1.062; 95% CI, 1.001 to 1.127; p = 0.047) contributed to sustained hip flexion contracture. CONCLUSIONS: Sustained hip flexion contracture frequently occurs after femoral lengthening in achondroplasia patients. Both excessive femoral lengthening and preoperative forward SVA tilt may contribute to the development of sustained hip flexion contracture in these patients.

Shear-wave elastography assessment of gluteal muscle contracture: Three case reports.

RATIONALE: Gluteal muscle contracture (GMC) is a clinical syndrome characterized by limited hip joint function due to fibrosis and contracture of the gluteal muscle and fascia fiber. Imaging examination is significant for its diagnosis and guidance of surgical treatment. PATIENT CONCERNS: This report presents 3 cases of GMC with bilateral involvement and summarizes the literature on the imaging findings of this disease. The clinical symptoms and presentations of the 3 cases well-matched the clinical diagnosis of GMC. Preoperative ultrasonography including elastography was performed. To our knowledge, studies based on the elastography findings of the disease are limited. DIAGNOSES: The diagnosis of GMC was finally confirmed by postoperative pathologic examination. INTERVENTIONS: All 3 patients then have a surgical therapy which cut off the contracture tract. OUTCOME: Symptoms of abnormal gait and limited hip joint function were greatly improved after surgical treatment. LESSONS: The elasticity of the GMC zone in patients with GMC is higher than that of the muscles in the corresponding sites of healthy people.

Lower extremity joint contracture according to ambulatory status in children with Duchenne muscular dystrophy.

BACKGROUND: Lower extremity joint contractures have negative effects on gait in children with Duchenne muscular dystrophy (DMD). Thus, contracture prevention is essential for maintaining a patient's functional ability and an acceptable quality of life. This study investigated hip flexion (HF), knee flexion (KF), and ankle joint plantar flexion (APF) contractures among male patients with DMD, based on the patients' ambulatory status. Differences in major joint contractures, based on passive stretching exercise participation, were also investigated. METHODS: A total of 128 boys with DMD, followed at the DMD clinic of a tertiary care hospital, were included in this cross-sectional study. The passive ranges-of-motion of the hip, knee, and ankle joints were measured, in the sagittal plane, using a goniometer. The Vignos Scale was used to grade ambulatory function. Boys with DMD who performed stretching exercises for more than 5 min/session, > 3 sessions/week, were classified into the stretching group. RESULTS: The HF (23.5o), KF (43.5o), and APF (34.5o) contracture angles in the non-ambulatory group were more severe than those in the ambulatory group. APF contractures (41 patients, 52.6%) were more frequently observed early, even within the ambulatory period, than were hip (8 patients, 10.3%), and knee joint (17 patients, 21.8%) contractures. Passive stretching exercises > 3 sessions/week were not associated with the degree of lower extremity joint contractures in the ambulatory or non-ambulatory group. CONCLUSION: HF, KF, and APF contractures are more common and severe when there is deterioration of ambulatory function. Stretching exercises alone are unlikely to prevent lower extremity joint contractures.

Prone Position-Induced Quadriceps Transcranial Motor Evoked Potentials Signal Loss-A Case Report.

BACKGROUND: Transcranial motor evoked potential (TcMEP) is widely used intraoperatively to monitor spinal cord and nerve root function. To our knowledge, there is no report regarding TcMEP signal loss purely caused by patient positioning during the spinal procedure. PURPOSE: The objective of this article is to report an intraoperative TcMEP signal loss of a patient with fixed sagittal imbalance posture along with mild hip contractures. STUDY DESIGN: A retrospective case report. METHODS: A 57-year-old man had fixed sagittal imbalance and flexed hip contractures. For a reconstruction surgery of T10 to the sacrum/ilium and L5 pedicle subtraction osteotomy (PSO), he was put in a prone position on a Jackson table. In order to accommodate his fixed hip flexion contracture, thigh pads were not used and pillows were placed under his bilateral thighs for cushioning. TcMEPs were used to assess lumbar nerve root function. Ten minutes after incision, bilateral vastus medialis TcMEPs were lost during spine exposure whereas all other data remained normal at baseline. The bilateral lower extremities were repositioned, with the knees flexed into a sling position to increase hip flexion. Five minutes after repositioning, the bilateral vastus medialis TcMEPs gradually improved and maintained baseline amplitude during the remainder of the surgery. RESULTS: No muscle weakness was detected immediately after surgery. The patient was discharged day 6 postoperatively with markedly improved posture and alignment. CONCLUSION: Insufficient hip flexion in patients with fixed sagittal imbalance and hip flexion contractures may cause TcMEP signal changes in the quadriceps response. TcMEP monitoring of bilateral lower extremities is highly recommended for patients with sagittal imbalance and hip contractures, with consideration for lower extremity repositioning when data degradation does not correlate with the actual spinal procedure being performed.

Slow correction of severe spastic hyperlordosis in an adult by means of magnetically expandable rods.

BACKGROUND: We describe a case of severe and progressive lumbar hyperlordosis (160°) in a 28-year-old female university student with cerebral palsy. Her main complaints were abdominal wall pain and increasing inability to sit in her custom wheelchair. METHOD: When deciding on our opinion about the most promising treatment strategy, we contemplated slow continued correction by means of percutaneously expandable magnetic rods (MAGEC) after the index surgery as a key component of a satisfactory correction in this severe and rigid curve. After an initial radical release and partial correction, a release and correction procedure was required for the bilateral hip flexion contracture. A final in situ posterior fusion was performed as a second spinal procedure, once the desired final correction at 66° of lumbar lordosis was achieved. RESULT: Three years after the completion of surgery, the patient has a stable clinical and radiological result as well as a solid posterior fusion on CT. CONCLUSION: This is the first case published in which percutaneous magnetic distraction was successfully used in an adult patient.

Endovascular Aortoiliac Revascularization in a Patient with Spinal Cord Injury and Hip Contracture.

Treatment of chronic peripheral ischemic wounds in patients with spinal cord injury (SCI) can be technically challenging, especially if they have significant hip contracture. This article describes the endovascular aortoiliac revascularization of a paraplegic patient with hip contracture and a hostile abdomen. It also reviews the particularity of the peripheral arterial system in SCI patients.

Clinical outcomes of arthroscopic surgery for external snapping hip.

BACKGROUND: Studies have reported on the arthroscopic technique for release of external snapping hip syndrome. However, no study with large sample size has been reported for arthroscopic surgery. METHODS: Patients with 229 bilateral and 19 unilateral external snapping hips were treated from January 2012 to June 2013. After locating the contracture position, arthroscopic surgery was performed accordingly. Preoperative and postoperative angles were compared. RESULTS: Comparing range of motion, all patients obtained higher adduction and flexion angles. At postoperative follow-up of 24 months, the adduction angle was improved from -14.4 ± 5.14 to 35.7 ± 4.21 for type I, from -31.2 ± 5.22 to 31.7 ± 2.84 for type II, from -49.0 ± 3.47 to 21.6 ± 3.43 for type III, and from -64.5 ± 4.65 to 18.3 ± 3.10 for type IV (P < 0.001). Similarly, the flexion angle was also significantly improved for all the four types (P < 0.001). Excellent ratio and satisfaction rate were good in types I and II. All the clinical features were cured after arthroscopic surgery. CONCLUSIONS: Arthroscopic surgery could be an effective procedure for external snapping hip, due to less operating time, small scar, fast postoperative recovery, and complete contracture release.

Treatment of the Lower Extremity Contracture/Deformities.

Lower extremity deformities of patients with arthrogryposis multiplex congenita present a wide spectrum of severity and deformity combinations. Treatment goals range from merely ensuring comfortable seating and shoe wear, to fully independent and active ambulation, but the overarching intention is to help realize the patient's greatest potential for independence and function. Treatment of hip and knee contractures and dislocations has become more interventional, whereas treatment of foot deformities has paradoxically become much less surgical. This article synopsizes the treatment strategies presented in September 2014 in Saint Petersburg, Russia at the second international symposium on arthrogryposis.