Tibialis anterior tendon transfer for residual dynamic supination deformity in treated club feet.

Twenty-seven previously treated club feet in 25 patients were evaluated retrospectively following tibialis anterior tendon transfer to the dorsum of the foot to correct residual dynamic supination deformity. In 11 feet, the transfer was combined with additional soft tissue and or bony procedures to treat other accompanying deformities. Electrophysiologically demonstrated peroneal weakness causing muscle imbalance contributed to the etiology of this dynamic deformity. At follow-up, none of the patients had dynamic supination deformity during ambulation. All showed active contraction of the transferred tibialis anterior tendon. There was no case of overcorrection. Functional and cosmetic results were assessed by parents and surgeons as being excellent. Tibialis anterior tendon transfer is recommended to correct residual dynamic supination deformity and to restore muscle balance after satisfactory correction of idiopathic club foot contractures.

Spinal manipulation results in immediate H-reflex changes in patients with unilateral disc herniation.

The aim of this clinical investigation was to determine whether the abnormal H-reflex complex present in patients with S1 nerve root compression due to lumbosacral disc herniation is improved by single-session lumbar manipulation. Twenty-four patients with unilateral disc herniation at the L5-S1 level underwent spinal H-reflex electro-physiological evaluation. This was carried out before and after single-session lumbar manipulation in the side-lying position. Eligibility criteria for inclusion in the study were: predominant sciatica, no motor or sphincteric involvement, unilateral disc herniation at the L5-S1 level on CT or MR imaging, age between 20 and 50 years. H-reflex responses were recorded bilaterally from the gastrosoleous muscle following stimulation of tibial sensory fibers in the popliteal fossa. H-reflex amplitude in millivolts (HR-A) and H-reflex latency in milliseconds (HR-L) were measured from the spinal reflex response. Pre- and post-manipulation measurements were compared between the affected side and the healthy side. Statistical evaluation was performed by the Wilcoxon matched-pairs test (SPSS). Thirteen patients displayed abnormal H-reflex parameters prior to lumbar manipulation, indicating an S1 nerve root lesion. The mean amplitude was found to be significantly lower on the side of disc herniation than on the normal, healthy side (P = 0.0037). Following manipulation, the abnormal HR-A increased significantly on the affected side while the normal HR-A on the healthy side remained unchanged (P = 0.0045). There was a significant difference between latencies on the affected side and those on the healthy side (P = 0.003). Following manipulation there was a trend toward decreased HR-L. However, this trend did not reach statistical significance (P = 0.3877). Eight patients displayed no H-reflex abnormalities before or after manipulation. Their respective HR-A and HR-L values did not change significantly following manipulation. Three additional patients were excluded due to technical difficulties in achieving manipulation or measuring spinal reflex. These observations may lend physiological support for the clinical effects of manipulative therapy in patients with degenerative disc disease.

Muscle imbalance in the aetiology of idiopathic club foot. An electromyographic study.

We performed electrophysiological studies on both legs of 52 children, aged from 3 months to 15 years, with idiopathic club foot. In only nine (17%) was no abnormality found. Isolated peroneal nerve damage was seen in 14 (27%). Abnormality of both peroneal and posterior tibial nerves was found in five (10%). Four patients (8%) had evidence of isolated spinal-cord dysfunction, whereas combined spinal-cord and peripheral-nerve lesions were seen in 14 (27%). Six patients (11%) had variable neurogenic electrophysiological patterns. In 13 patients in whom the studies were repeated neither progression nor improvement of the electrophysiological parameters was observed. Pathological electrophysiological findings were found in 66% of conservatively-treated patients. In the 43 patients treated surgically, all 16 with fair and poor results had pathological electrophysiological findings and 12 required further operations. Multiplicity of the pathological findings was related to the severity of the deformity of the foot; normal studies represent a good prognostic sign. Electrophysiological studies are useful in idiopathic club foot with residual deformities after conservative or operative treatment. Our findings support the theory that muscle imbalance is an aetiological factor in idiopathic club foot.

Perthes' disease and posterior lumbosacral union.

Delayed bone development is common in Perthes' disease, and affected children are usually smaller than normal. Somatosensory evoked potentials (SEP) studied in 25 cases of Perthes' disease were normal. Fifty-four patients with active or healed Perthes' disease were examined. Every child aged less than 8 years showed failure of posterior lumbar and/or sacral fusion. With growth, fusion increased so that at age 14 years 50% had a normal fusion and 50% had spina bifida occulta. At age greater than 16 years, the incidence was similar to that in the general population. In Perthes' disease, growth in fusion of the lumbosacral elements is delayed.

Transient suppression of involuntary movements in cerebral palsy patients during dental treatment.

The efficacy of nitrous oxide (N2O) and oxygen (O2) inhalation in reducing involuntary movements in cerebral palsy (CP) dental patients was examined using electromyography (EMG) and H-reflex techniques. Quantification and analysis of the EMG data revealed a progressive elimination of these movements to a point resembling the state of a normal muscle at rest. There was a gradual decline in the number of bursts and an increase in the silent periods of the EMG while under N2O. The recovery period after cessation of N2O was characterized by a successive increase in the number of bursts and a simultaneous decrease in the silent periods of the EMG to a state similar to the baseline recorded prior to inhalation of N2O/O2. The H-reflex also was found to decrease gradually during inhalation of N2O/O2 to about one-half of the baseline. This parameter also returned to baseline after N2O wash-out. Our findings demonstrate quantitatively the effectiveness of N2O in reducing the central motor neuron pool excitability to an extent that suppresses involuntary movements and allows more controllable and comfortable dental management.

Nontraumatic, acute neonatal paraplegia.

Nontraumatic, acute neonatal paraplegia with associated lower limb vascular phenomena is a relatively rare condition. Three such cases are reported. The paralysis is primarily motor with minimal neurologic recovery. Contractures and bizarre deformities develop at an early stage and necessitate repeated orthopaedic intervention. The most likely etiology appears to be a vascular insult to the spinal cord.