The assessment of prognosis in Perthes' disease.

Seventy children who had suffered from Perthes' disease were reviewed clinically and radiologically three to eight years from the onset of the condition in order to determine retrospectively the most satisfactory method of assessing the prognosis and the correlation between the clinical and radiological result. In younger children the femoral head was more likely to be spherical at the conclusion of the pathological process but not necessarily of normal proportions nor normally covered by the acetabulum. The prognosis was significantly poorer for girls than for boys. Clinical factors were not an aid to prognosis in the individual cases, but overall there was a close correlation between the clinical and the radiological end-results. The most reliable radiological factors indicating the prognosis were the extent of uncovering of the femoral head, the Catterall grouping, the presence of calcification lateral to the outer limit of the acetabulum and lateral displacement of the femoral head, as measured by comparing the head to tear-drop distances on each side.

Correction of coxa vara in childhood. The use of Pauwels' Y-shaped osteotomy.

The long-term results following the correction of coxa vara by Pauwels' Y-shaped intertrochanteric osteotomy have been evaluated in 14 children. Ten of the children had unilateral hip disease and were otherwise normal while four had bilateral hip disease due to generalised skeletal dysplasias. In each case, the growth plate was vertical, the femoral head was displaced inferiorly and there were abnormalities in the metaphysis of the femoral neck. The results indicate that this osteotomy provides lasting correction of the deformity, regardless of the cause, as long as the inclination of the growth plate is corrected to 40 degrees or less and adequate support is provided for the metaphyseal defect and the displaced femoral head.

Medial physeal stapling for primary and secondary genu valgum in late childhood and adolescence.

We report the results of medial physeal stapling in 16 knees with primary genu valgum and 27 with secondary genu valgum. In the primary group, stapling was undertaken at a mean chronological age of 12 years in girls and 13 years in boys. The medial femoral physis was stapled in ten knees and the medial femoral and tibial physes in six knees. At skeletal maturity, all patients had excellent or good leg alignment. Secondary genu valgum is due to skeletal dysplasia, haematological or endocrine disorders, or to juvenile chronic arthritis. Stapling was at a mean chronological age of 11 years in girls and 14 years in boys. The medial femoral physis was stapled in 13 knees, the medial tibial physis in three and both in 11 knees. At skeletal maturity, 85% had excellent or good leg alignment, and correction had occurred within one year. Two of the poor results were due to staple extrusion from osteoporotic bone, and two to overcorrection. Rebound growth was minimal and unpredictable after the removal of staples. Medial physeal stapling is a suitable method of treatment for both primary and secondary genu valgum in late childhood and in adolescence. At least one year of knee growth is required to achieve correction, and care is needed to avoid overcorrection of the secondary genu valgum.

Resection for symptomatic talocalcaneal coalition.

Over a nine-year period, 20 feet with persistently symptomatic talocalcaneal coalition were treated by resection of the bar. The 17 patients were all under 16 years of age. Excellent or good long-term results were achieved in the ten feet in which preoperative coronal CT had shown that the area of coalition measured 50% or less of the area of the posterior facet of the calcaneum. In these feet heel valgus was less than 16 degrees and there were no radiographic signs of arthritis of the posterior talocalcaneal joint. Talar beaking was present in 70% of these feet but it did not impair the clinical result. Fair or poor results were observed in the ten feet in which preoperative CT had shown the area of relative coalition to be greater than 50%. In these feet, heel valgus was greater than 16 degrees and most had narrowing of the posterior talocalcaneal joint and impingement of the lateral process of the talus on the calcaneum.

Surgical treatment of double major scoliosis. Improvement of the lumbar curve after fusion of the thoracic curve.

We have evaluated two methods of surgical treatment of adolescent idiopathic double major scoliosis in 59 patients. In group 1, 31 patients were treated by fusion of the upper curve only. In group 2, 28 patients had lumbar fusions also including most of the lower curve. The magnitude of the lower curve and the correction obtained in traction were good indicators of the correction achieved postoperatively. Forty-four patients were reviewed at a minimum of 10 years after operation. Those in group 1 showed sustained improvement of the lower curve with minimal stiffness and pain. Group 2 patients had lumbar curves of similar severity at review, but had significantly more low back pain and stiffness. The number of lumbar segments which remained mobile appeared to be a critical factor in determining the outcome. Selective fusion of the upper curve in double major scoliosis produces satisfactory results if the lumbar curve is less than 50 degrees. It may also be appropriate for flexible lumbar curves of larger angle.

Epiphyseolysis for partial growth plate arrest. Results after four years or at maturity.

We reviewed 13 children with partial growth plate arrest who had been treated by epiphyseolysis. Eight were followed to skeletal maturity and five for at least four years. In three cases the affected limb was restored to normal and in five the operation was successful in improving angular deformity and leg length discrepancy such that further surgery was not necessary. In the five failures, angular deformity had progressed or limb length discrepancy had increased. There were no significant complications and the procedure did not prevent subsequent osteotomy or limb length equalisation. Epiphyseolysis was most effective for small bars and those affecting only the central area of the plate.

Torticollis due to a combination of sternomastoid contracture and congenital vertebral anomalies.

We report four children with sternomastoid contracture combined with torticolis secondary to congenital vertebral anomalies. Two had features of Klippel-Feil syndrome and a proximal release of the contracted sternomastoid produced good cosmetic correction initially. Progression of the deformity occurred subsequently without recurrence of sternomastoid contracture. One child had such mild deformity that it was merely observed. The fourth child was born with torticollis without sternomastoid tightness and a vertebral anomaly was later recognised. He slowly developed a sternomastoid contracture and his condition was considerably improved by sternomastoid release. This combination of causes of torticollis has not, as far as we know, been previously reported. The clinician should be aware of it and should also realise that radiographs of the very immature spine may not disclose the bony anomalies.

Chest wall deformity in patients with repaired esophageal atresia.

Chest wall deformities developed after thoracotomy for esophageal atresia, in 77 of 232 patients (33%) who did not have a congenital vertebral anomaly. Anterior chest wall asymmetry was present in 47, scoliosis in 18 and a combination of both in 12 patients. Scoliosis was convex away from the incision in two thirds of those affected. Anterior chest wall deformity was more common in patients greater than 25 years of age, and scoliosis was more common in patients who had had multiple thoracotomies. Breast surgery to minimize inequality was required in three female patients, and spinal surgery in one patient. Twenty-two of 53 patients with a congenital vertebral anomaly developed scoliosis, eight of whom required surgery. The scoliosis was probably the result of the vertebral anomaly in these patients, who are particularly at risk for progressive deformity.

AIDS and pregnancy. Survey of knowledge, attitudes, beliefs, and self-identification of risk.

A descriptive educational needs assessment was conducted at a southwestern military medical center on knowledge, attitudes, beliefs, and self-identification of risk factors for acquired immunodeficiency syndrome (AIDS). A self-report questionnaire was administered to 700 pregnant women. Misinformation and lack of knowledge about AIDS were identified. A small group of women reported that they were at risk for AIDS. The study findings support a need for AIDS educational programs for childbearing women.

Muscle abnormalities in idiopathic toe-walkers.

The cause of toe-walking is unknown. Muscle biopsies were taken from a group of 25 toe-walkers who were treated at this hospital to try to identify the pathological cause of the condition. The most common abnormality noted was an increase in the proportion of type I muscle fibers with type grouping; other less common changes included the presence of angulated atrophic fibers and thickened capillaries and cases in which occasional fibers were undergoing active degeneration and regeneration. The combination of these changes suggests that there may be an underlying neuropathic process in idiopathic toe-walkers.

Idiopathic toe-walking: does treatment alter the natural history?

Outcomes from observation or cast or surgical treatment of idiopathic toe-walking were determined in 136 children. With patient-determined outcomes, for the observation group, gait was normal in 6%, improved in 45%, and unchanged in 49%. Physician-determined outcomes demonstrated normal gait in 12% of children. Outcomes were similar in the cast group. With patient-determined outcomes in the surgical group, 22% walked normally, 50% had improved, 26% were unchanged, and 2% had deteriorated; with physician-determined outcomes, 37% walked normally. The natural history, determined from the observation group, was for idiopathic toe-walking to persist, albeit with improvement in 50%. Cast treatment did not alter the natural history. Surgical treatment may influence the outcome, but indications for surgery need to be clarified.

A new approach to lateral cutaneous nerve of thigh block.

A new approach to the lateral cutaneous nerve of thigh is described. It depends on locating the depth of the canal through which the nerve passes immediately medial to the anterior superior iliac spine. Anatomical dissections show that it lies deep to the attachments of external oblique aponeurosis, the internal oblique muscle, and a deep fascial layer. Two district 'pops' or loss of resistance can be identified during insertion of a short-bevelled needle. Location of the canal by the technique described has been confirmed radiographically.

Bilateral hypoplastic calcanei.

A previously undescribed anomaly of the calcaneus occurred in an otherwise healthy 2-month-old girl. There was marked bilateral hypoplasia of the calcanei, involving approximately the posterior half of each. The child stood at 15 months and walked at 22 months. At age 5 years, the child had a slight in-toed gait that corrected with dorsiflexion. Her only problem has been some difficulty with shoeware. The etiology of this anomaly remains conjectural.

Osteochondritis of the first metatarsal epiphysis.

Two cases of painful osteochondritis of the basal epiphysis of the first metatarsal are described. Complete resolution without deformity was achieved in both patients. We suggest that this condition be considered in the differential diagnosis of transitory foot pain in childhood.

Spinal deformity in patients born with oesophageal atresia and tracheo-oesophageal fistula.

Spinal deformity was present in 58 (19%) of 302 patients born with oesophageal atresia and fistula when examined at review. This was present in 24 (47%) of 51 patients with vertebral anomalies and 34 (14%) of 251 patients with normal vertebrae. Scoliosis was present in 21 patients with vertebral anomalies, torticollis in two, and lordosis in one. Two thirds of the patients with congenital scoliosis have had or are likely to require operation, compared with five patients with non-congenital scoliosis. Scoliosis associated with mixed vertebral anomalies in the lower thoracic spine had the worst prognosis. The medical records of a further 64 patients who had survived operation but who could not be traced were reviewed, and indicated that four had had congenital vertebral anomalies but none had a spinal deformity. We recommend early detection of vertebral anomalies in this group and careful follow up of patients with these abnormalities.

Efficacy of surgical management for scoliosis in myelomeningocele: correction of deformity and alteration of functional status.

The effect of spinal fusion for paralytic scoliosis in 49 patients with myelomeningocele was studied. Improved sitting balance was seen in 70% of the patients following anterior and posterior fusions, 67% following posterior fusion alone, and 28% after anterior fusion alone. The ability to ambulate was adversely affected in 67% of the patients who had undergone combined anterior and posterior fusions, in 57% following anterior fusion alone, and in 27% following posterior fusion alone. Sitting is likely to be improved but ambulation may be more difficult following spinal correction and fusion.

Accessory diaphragm contributing to respiratory insufficiency in a child with progressive thoracolumbar spinal scoliosis.

A patient with an accessory right diaphragm discovered during thoracotomy for correction of severe thoracolumbar scoliosis is presented to illustrate the diagnostic difficulties that may occur in children with accessory diaphragm. The patient had presented at an early age with respiratory symptoms which were assumed to be asthmatic in aetiology and complicated by progressive chest deformity. The respiratory symptoms in accessory diaphragm can be improved by surgery.

Pulmonary restrictive effect of bracing in mild idiopathic scoliosis.

The use of bracing in the treatment of mild idiopathic scoliosis is controversial. A study of 33 adolescents showed that bracing significantly decreased lung volumes. Functional residual capacity was reduced by a mean of 26%, 18% of children showing a reduction of greater than 40%. The mean reduction in total lung capacity was 16% and in forced vital capacity 18%. This restriction of lung function by bracing might have a deleterious effect on lung growth or might impose an additional risk factor in the presence of other disorders, such as asthma and diaphragmatic weakness. The use of bracing in individuals with mild scoliosis should be judiciously reassessed.

Bilateral metachronous periosteal osteosarcoma.

The first case of bilateral metachronous periosteal osteosarcoma (OS) is reported. A 14-year-old white boy presented with a 1-month history of pain and swelling in his right thigh. Periosteal OS was diagnosed on a basis of the radiologic and pathologic findings. Treatment was with local resection and total hip replacement after a short course of high-dose methotrexate; multi-agent chemotherapy was continued postoperatively for 3 months. He remained well for 3 years. He then represented with a mass in the left femur that had been slowly growing for about 1 year. Radiologic and biopsy studies showed periosteal OS. Full investigations showed no evidence of metastatic disease. Treatment consisted of local resection without chemotherapy. He remained well for 6 months after the second excision until developing multiple pulmonary metastases. All further therapy was refused. The question as to whether the second tumor was a new primary lesion or a metastasis is discussed, together with possible differential diagnoses.

Which implant for proximal femoral osteotomy in children? A comparison of the AO (ASIF) 90 degree fixed-angle blade plate and the Richards intermediate hip screw.

We reviewed the clinical and radiologic results of 164 proximal femoral osteotomies in 132 children using the AO (ASIF) 90 degree fixed-angle blade plate and the Richards intermediate hip screw to establish the clinical and radiologic outcomes, establish the incidence of complications, and determine the relative indications and contraindications for the two implants. The incidence of complication in this series was 9% (15 complications in 14 osteotomies in 13 patients) including one bursitis, one wound breakdown with exposure of the underlying plate, five infections, two peroneal nerve palsies, one fractured shaft of femur, one fractured neck of femur, two technical errors, one painful nonunion, and one loss of fixation. There were five (3%) revisions in total. Fifty-six osteotomies in 44 patients were performed using the Richards intermediate hip screw, and 108 osteotomies were performed in 88 patients using the AO 90 degree fixed-angle blade plate. We found that both implants were effective with an acceptable rate of complications and revision surgery.