Aponeurotic release of semimembranosus: A technical note to increase correction gained with hamstring lengthening surgery in cerebral palsy.

OBJECTIVE: The aim of this study was to determine the intraoperative corrective effect of the aponeurotic release of semimembranosus (SM) as a single procedure or an adjunct procedure to distal myotendinous release of semitendinosus (ST) and myofascial release of SM lengthening in the correction of knee flexion deformity in cerebral palsy (CP). METHODS: In this prospective study, 46 knees of 23 consecutive ambulatory patients (15 boys and 8 girls; mean age=8.33 years; age range=5-12 years) with spastic diplegic CP with a gross motor function classification system level (GMFCS) II or III were included. The patients were then divided into 2 groups. In group I, there were 10 patients (4 boys, 6 girls; mean age=8.6±2), and combined release of ST in the myotendinous junction and SM in the myofascial junction, followed by aponeurotic release of SM were carried out. In group II, there were 13 patients (2 girls, 11 boys; mean age=8±2.35), and aponeurotic release of SM was done first and followed by the combined release of ST in the distal myotendinous junction and the myofascial release of SM. Intraoperative popliteal angle (PA) measurements were recorded in each group. RESULTS: PA was reduced from 58.1°±7.6° (range=46°-75°) to 41.2°±8.8° (range=20°-54°) in group 1 and from 59.1°±11.3° (range=40°-87°) to 42.7°±10.8° (range=24°-64°) in group 2. No significant difference was observed between the groups in terms of reduction in PA (p=0.867). In group 1, adding the aponeurotic release of SM further reduced the PA to 31.7°± 8.5° (range=14°-47°) (p=0.002). In group 2, adding the myotendinous release of ST and myofascial release of SM further reduced the PA to 32.9°±7.2° (range=16°-44°) (p=0.004). There was no significant difference between the final PA values in the 2 groups (p=0.662). There was no difference in terms of early complications. CONCLUSION: Aponeurotic release of SM is equally effective to reduce the intraoperative PA with combined myotendinous release of ST and myofascial release of SM. Combining all the 3 procedures provides a better correction without forceful manipulation or lengthening of the lateral hamstrings during the correction of knee flexion deformity in CP.

Growth Modulation for Knee Coronal Plane Deformities in Children With Nutritional Rickets: A Prospective Series With Treatment Algorithm.

To report prospectively the radioclinical outcome of guided growth surgery for coronal plane deformities around the knee in young children with nutritional rickets on the intermediate term, to assess the responsiveness of torsional deformities of the tibias to guided growth regarding function and objective clinical parameters, and to propose a treatment algorithm. Methods: Fifty children (male:female, 27:23) with knee coronal plane deformities (knees:physes, 86:99), (varum:valgum, 51:35) secondary to nutritional rickets were subjected to femoral and/or tibial temporary hemiepiphysiodesis using a two-hole 8-plate. The mean age at implantation was 3.8 ± 1.5 years (range 2.5 to 5). The mean follow-up was 2.8 years (range 2 to 4). All children received a standing full-length AP radiographs of both lower limbs in neutral rotation to measure the mechanical axis deviation, tibiofemoral angle, and joint orientation angles. Tibial torsion was objectively assessed by measuring the bimalleolar axis. Results: The radiologic measurements, tibiofemoral angle, mechanical axis deviation, mechanical lateral distal femoral angle, medial proximal tibial angle, and Hilgenreiner-epiphyseal angle, showed a highly statistically significant improvement (P ≤ 0.001). Radiographic outcomes correlated with their clinical counterparts. The mean duration of correction of the mechanical axis was 10.8 ± 2.4 months (7 to 21). The mean follow-up for rebound of the deformity was 1.5 years (range 1 to 3). Conclusion: The radioclinical outcome is rewarding with a tolerable complication profile. The mechanical complications were mostly related to lengthy implant retainment encountered in severe deformities. Internal tibial torsion seems profoundly responsive to correction of coronal plane deformity. And, derotation osteotomies are rarely justified. Our proposed algorithm may be used as a decision-taking guide for achieving the desired growth modulation in a more efficient manner.

[Elbow contracture caused by increased tonus of the flexor muscles]. / Die Kontraktur des Ellenbogens durch erhöhten Tonus der Beugermuskulatur.

Increased muscle tone leads occasionally to fixed flexion and supination deformities of the elbow in tetraplegics and subsequently to additional restriction of function. The incidence, course, remaining functions and therapeutic measures were studied retrospectively in 22 patients (37 arms). Muscle hypertonus was found to start during the first 12 weeks after spinal cord lesion and to provoke a flexion contracture of 35 to 95 degrees in 40% of the cases despite therapy. Due to the failure of physical therapy and operative measures, prophylaxis through the prevention of shoulder-pain, early use of adequate splinting of the upper extremity and electrical stimulation of the triceps brachii should be carried out.