Effectiveness of bracing in male patients with idiopathic scoliosis.

STUDY DESIGN: A review of a clinical series was performed. OBJECTIVE: To assess the effectiveness of orthotic treatment in male patients with idiopathic scoliosis and to compare with published data on female patients. SUMMARY OF BACKGROUND DATA: Although males have been included in bracing studies, the number of males has been small, and there have been no studies of exclusively male braced patients. METHODS: The medical records of 112 males with idiopathic scoliosis age > or =10 years who were prescribed orthoses were reviewed to confirm idiopathic etiology, determine the brace prescribed, and estimate compliance. Cobb angles and Risser signs were measured from radiographs at presentation, brace prescription, brace discontinuation, and final follow-up. Progression was defined as an increase in curve magnitude of 6 degrees. Surgical progression was defined as progression to 50 degrees and/or arthrodesis. The average age at brace prescription was 13.9 years, and 66% were Risser 0. Duration of treatment averaged 3.1 years. Curve magnitude at brace prescription averaged 33.1 degrees. The patients were observed an average of 1.2 years after the brace was discontinued. RESULTS: Progression of 6 degrees occurred in 74% of boys, and 46% reached surgical thresholds. Curve progression was related to immature Risser status but not to age or curve magnitude. Progression to surgery was related to immature Risser status and initial curve magnitude. Curves measuring > or =30 degrees progressed to surgical magnitudes in >50% of patients. Compliance was good in only 38% of patients. CONCLUSIONS: Bracing of male patients with idiopathic scoliosis is ineffective. Curves measuring > or =30 degrees are very likely to progress to surgery, especially in immature patients.

Efficacy of perioperative halo-gravity traction in the treatment of severe scoliosis in children.

SUMMARY: Perioperative halo traction was used in the treatment of severe scoliosis in 19 children. Diagnoses included neuromuscular, idiopathic, and congenital scoliosis. Traction was transferable between the bed and a walker or wheelchair. Thirteen patients had prior spinal surgery, and most required osteotomy. Traction was used for 6 to 21 weeks. All patients underwent spinal fusion surgery after traction, with instrumentation used in 15 patients. Improvement was achieved in all patients. The Cobb angle improved 35% from an average 84 degrees before traction (range 63 degrees -100 degrees ) to 55 degrees preceding fusion. Trunk decompensation improved in all patients. Trunk height increased 5.3 cm in traction. Response to traction did not correlate with diagnosis, patient age, or prior surgery. There were no neurologic complications. Perioperative halo-gravity traction improves trunk balance and frontal and sagittal alignment in children with severe spinal deformity. Surgical fusion was enhanced by the improved alignment, and neurologic injury was avoided.

Effectiveness of femoral varus osteotomy in patients with cerebral palsy.

This is a retrospective review of 144 hips in 99 patients treated with femoral varus osteotomy between 1975 and 1995. Average follow-up was 5 years (range, 2-15 years). The majority of patients (67%) were nonambulatory spastic quadriparetics. The average age at the time of surgery was 7.7 years (range, 3-15 years). Radiographic parameters analyzed were the neck-shaft and center-edge (CE) angles and Reimer's migration index (MI). Results were considered good if the CE angle was >20 degrees and the MI <30%, fair if the CE angle was 0 degrees - 20 degrees and the MI 30-50%, and poor if the patient had persistent pain, a CE angle of <0 degrees , or an MI >50%. Twelve hips (8%) remained painful at final follow-up, and 12 hips (8%) dislocated despite surgery. Previous surgery, unilateral surgery, performing a pelvic osteotomy, and age at the time of surgery had no statistical influence on outcome. Good results were obtained in 43.1%, fair in 41.5%, and poor in 15.4%. Only the quality of the reduction obtained at surgery, judged by the increase in CE angle and the reduction in MI, had a statistical influence on final result. Athetoid patients fared as well as those with spasticity. Femoral varus osteotomy was effective in providing a stable pain-free hip in 84% of patients.

Gait and function after intra-articular arthrodesis of the hip in adolescents.

BACKGROUND: Patients who have had a hip arthrodesis have been reported to have pain in the back and the knee due to an altered gait. There is little information about the specific compensatory mechanisms that are adopted when walking. The purpose of this study was to objectively define gait adaptations after an arthrodesis of the hip and to correlate the kinematic findings with pain and other patient outcomes. METHODS: Nine patients who had had an arthrodesis of the hip at an average age of thirteen years and five months (range, ten years and nine months to sixteen years and eleven months) were evaluated with gait analysis and muscle strength-testing and completed a questionnaire related to pain and function. The average duration of follow-up was eight years and ten months (range, two years and one month to thirteen years and ten months). The frequency of the postoperative visits varied. Seven patients were adults at the time of the study and were called back specifically for the study. RESULTS: All patients had decreased cadence and step lengths. The kinematic findings included decreased dorsiflexion of the ipsilateral ankle, hyperextension of the ipsilateral knee during the stance phase, and a tendency toward increased genu valgum during gait. In normal gait, there is no genu varum or valgum during the stance phase. The patients had an average (and standard deviation) of 7 +/- 4 degrees of genu valgum. Pelvic and lumbar motion in the sagittal plane was excessive in all patients. Strength-testing revealed clinically relevant weakness in the ipsilateral quadriceps in all patients, with a difference of more than 20 percent between the two extremities in six patients. The gastrocnemius. soleus muscle was stronger on the side with the fused hip in six patients. The questionnaire, designed by Harris in 1969 and completed by the patients at the time of the gait analysis, revealed back pain in seven patients. The questionnaire was administered only once. The functional outcome as measured with use of the same questionnaire worsened as the duration of follow-up increased. CONCLUSIONS: The gait analysis showed excessive motion in the lumbar spine and the ipsilateral knee in all nine patients. This abnormal motion led to pain as the duration of follow-up increased, and all patients who had been followed for four or more years after the arthrodesis complained of back pain. We hypothesized that excessive motion for an extended duration can lead to back pain. The preferred position of the hip for the arthrodesis was 20 to 25 degrees of flexion, neutral abduction-adduction, and neutral rotation.

Gait analysis and muscle strength in children with congenital pseudarthrosis of the tibia: the effect of treatment.

Twelve patients with healed congenital pseudarthrosis of the tibia underwent gait analysis and muscle strength testing to determine the functional result of treatment. Six children younger than 4 years of age presented with pseudarthroses (early onset), and six children first fractured at older than 4 years of age (delayed onset). Four children with amputations as final treatment for congenital pseudarthrosis were studied for comparison. The early-onset group had undergone an average of 4.2 surgeries and all required transankle fixation. The delayed-onset group had undergone an average of 1.5 surgeries, with one child requiring fixation across the ankle. Lack of ankle push-off and foot drop occurred in the early-onset group. Terminal stance phase ankle power generation was greatly diminished in the early-onset group. Total mechanical work performed by the affected limb, when compared to the uninvolved contralateral limb, was symmetric in delayed-onset patients and reduced by 68% in early-onset patients and by 85% in amputees. Gastrocsoleus strength was reduced by 40%. Gait and muscle strength of patients with "healed" congenital pseudarthrosis of the tibia are markedly disturbed. Early onset of disease, early surgery, and transankle fixation lead to an inefficient gait comparable to that of amputees.

Rotational deformities in the lower extremities.

Rotational abnormalities of the lower extremities remain a significant complaint among parents of pediatric patients. Intoeing can result from metatarsus adductus, internal tibial torsion, or femoral anteversion. Rarely is orthopedic treatment necessary. Current recommendations regarding the treatment of intoeing are given.

Gait analysis and muscle strength in children with surgically treated clubfeet.

Twenty-three children who had unilateral surgery for idiopathic clubfeet underwent gait analysis and isokinetic muscle-strength testing at an average of 10 years after surgical release. Ankle sagittal-plane kinematics were disturbed in 20 clubfeet. Fifteen children had an internal foot-progression angle. Genu valgum and knee hyperextension were common. Plantarflexion power was decreased by 23% on the side of surgery (p = 0.00005). Quadriceps weakness (defined as a decrease in strength >10% of the nonoperated-on limb's strength) was seen in nine of 22 operated-on limbs and hamstring weakness in eight of 22. Gastrocsoleus weakness exceeded 10% in 16 of 21 clubfeet. Average weakness of the gastrocsoleus was 27% (p < 0.05). Ten-year analysis of children treated with clubfoot releases revealed disturbances in ankle motion and strength. Loss of plantarflexion power and gastrocsoleus strength can be predicted by Achilles tendon lengthening. Knee kinematic abnormalities and weakness also were seen. These abnormalities produce functional difficulties in gait and may lead to degenerative changes later.

Reproducibility in the measurement of atlanto-occipital instability in children with Down syndrome.

STUDY DESIGN: This study compared the reproducibility of three techniques used to measure translation between the occiput and C1 in children with Down syndrome. OBJECTIVES: Intraobserver and interobserver variability were computed to determine if there is a reliable way to measure occiput-C1 instability. SUMMARY OF BACKGROUND DATA: No studies have been performed comparing measurement techniques in children with Dow syndrome. METHODS: Powers ratios, basion-axial intervals, and translational anteroposterior motion as described by Wiesel and Rothman were calculated for 50 pairs of flexion-extension lateral cervical radiographs from children with Down syndrome. Calculations were made on two occasions by four reviewers. RESULTS: Mean differences between measurements for two observers were 0.14 for the Powers ratio, 1.3 mm for the Wiesel technique, and 1.8 mm for the basion-axial interval. The 95th percentiles of the differences between measurements for two observers were 0.38 for Powers ratios, 3.5 mm for the Wiesel technique, and 5.3 mm for the basion-axial interval. CONCLUSIONS: Measurement of atlanto-occipital translation by any of these methods is not reproducible. Although the technique by Wiesel and Rothman is the easiest to apply, confirmation of instability with magnetic resonance imaging should guide management.

Open fractures of the tibia and femur in children.

Forty-seven children with 32 open tibial fractures, 11 open femoral fractures, and six closed tibial fractures with compartment syndrome, which were surgically opened, were assessed for the time to union and incidence of nonunion and infection. Treatment varied with fracture severity and patient age. Tibial external fixators were supplemented by short-leg casts, and fixators were removed at an average of 7 weeks. No child required further surgery to achieve union. There was one (2%) delayed union and no nonunions. Three fractures (6%) developed infections. No pin-tract infections occurred in tibial fractures treated with external fixation with casting. The relation between age and time to union was statistically significant. In open fractures without segmental bone loss or soft-tissue loss requiring major reconstruction, bony healing can be expected within 6 months.

Severe lumbar lordosis after dorsal rhizotomy.

Two children with spastic quadriplegia who developed excessive lumbar lordosis after selective dorsal rhizotomy are described. The rhizotomy did not change the ambulatory status of either child (one nonambulator, one household ambulator). Preservation of unopposed hip flexion in the presence of multiple laminectomies may lead to the development of a lordotic deformity in children who sit most of the time. Excessive lumbar lordosis may cause pain and difficulty in sitting. Surgical correction of this deformity is complex because of the removal of posterior elements during the rhizotomy.

Orthopedic management in myelomeningocele.

Paralysis, muscle imbalance, and spasticity resulting from myelomeningocele produce orthopedic deformities that often require surgical correction. Spinal deformities in myelomeningocele are nearly universal, and are difficult to treat because of the absence of posterior elements. Hip dislocations frequently occur, but rarely require treatment. Severe foot deformities are seen in up to 80% of children.

Biomechanical analysis of single- versus double-screw fixation in slipped capital femoral epiphysis at physiological load levels.

Slipped capital femoral epiphyses in 12 pairs of bovine femora were pinned with a single screw on one side and two screws on the other. The specimens were subjected to physiological shear loads across the epiphysis (100 cycles at 1.1 Hz; 400 N for slow walking, and 900 N for fast walking). The rates of creep were decreased 23% with double screws compared to single screws at slow walking, and 30% at fast walking; this was not statistically significant. Single-screw fixation in slipped epiphyses is thus recommended, because the small gains in resistance to cyclic creep at physiological loading were not statistically different, and did not offset the increased risks of complications with multiple screws.

Three-dimensional sonographic evaluation of developmental dysplasia of the hip: preliminary findings.

PURPOSE: To determine the value of three-dimensional (3D) sonography in the evaluation of developmental dysplasia of the hip. MATERIALS AND METHODS: 3D reconstruction and section analysis were performed on 38 data acquisitions obtained in nine patients with a clinical diagnosis of developmental dysplasia of the hip. Data were obtained mostly in the coronal plane, and section-analysis and 3D volume reconstruction images were generated. RESULTS: Of the 32 image sets obtained in the coronal plane, the technical quality of 27 (84%) section-analysis images and 25 (78%) spatial-revolving images was judged to be satisfactory. CONCLUSION: In addition to permitting global visualization of the hip, 3D sonography offers imaging in the sagittal and craniocaudal projections, something no other modality can offer. 3D sonography can also demonstrate the relationship of the femoral head to the acetabulum and femoral head containment more thoroughly than does conventional sonography.

Progression of the curve in boys who have idiopathic scoliosis.

The prevalence of curve progression was evaluated in 210 boys who had idiopathic scoliosis. A minimum age of eight years, a deformity of at least 10 degrees, and radiographic follow-up of one year or progression of the curve within the first year of follow-up were the criteria for inclusion in the study. Of the 210 patients, sixty-eight (32 per cent) had progression of 10 degrees or more. Four of the five patients who had had an initial curve of 50 degrees or more subsequently had a spinal arthrodesis. The risk of progression was significantly greater for patients who were at an earlier Risser stage (p < 0.002) and for those who were younger (p < 0.005). The risk of progression was also greater for patients who had had a larger curve at the time of presentation; of the sixty-three boys for whom the Risser grade was 1, 2, 3, 4, or 5 when they were first seen and who had a curve of 25 degrees or more, twenty (32 per cent) had progression, compared with only two (5 per cent) of the thirty-eight who had a Risser grade of 1, 2, 3, 4, or 5 and a curve of 24 degrees or less. Of the thirty-four patients for whom the Risser grade was 4 when they were first seen, five (15 per cent) had progression.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemodynamic instability of myelomeningocele patients during anterior spinal surgery.

Surgery for spinal fusion for patients with myelomeningocele is accompanied by a high rate of complications. The authors report six cases of sudden intra-operative hemodynamic instability which occurred during anterior spinal fusion; the procedures had to be aborted. All children were successfully resuscitated and four patients subsequently underwent successful anterior and posterior spinal fusion. Four of the children had positive skin and serum allergy tests to latex.

Influence of pelvic osteotomy on birth canal size.

Six pelvic osteotomies (Salter, Sutherland, Steel, Tönnis, Chiari, and periacetabular) were performed on the right hemipelvis of adult female pelvic plastic models. Each pelvis underwent conventional X-ray and computed tomographic digital pelvimetry before and after osteotomy. The change in the anteroposterior and transverse dimensions at the inlet, midpelvis, and outlet were calculated. None of the osteotomies significantly decreased the inlet. The Salter and Sutherland osteotomies decreased the midpelvis to borderline low. The Salter, Sutherland, and Steel osteotomies significantly decreased the pelvic outlet. These changes correlated closely with those in living patients. Much of this decrease is nullified when the osteotomy is performed prior to the pubertal growth spurt.

Single versus double screw fixation for treatment of slipped capital femoral epiphysis: a biomechanical analysis.

Slipped capital femoral epiphyses (SCFE) were created in 10 pair of bovine femurs. Each pair was pinned with a single screw on one side and two screws contralaterally. The specimens were reloaded to failure. Double pin fixation yielded only a 33% increase in stiffness as compared with single pin fixation. Resistance to further slip was not proportional to screw number. The stiffness of neither double nor single screw fixation approximated that of the intact physis. Single screw fixation in slipped epiphyses is recommended because the small gains in stiffness with a second screw do not offset the risk of complications.