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.

Gluteal muscle fibrosis with abduction contracture of the hip.

PURPOSE: Gluteal muscle fibrosis with hip contracture is a rare condition and causes major disability; literature reports are sparse. The aim of this study is to present, for the first time in Iraq and the region, a case series of gluteal fibrosis and the results of surgical treatment. METHODS: Seven children--six boys and one girl--diagnosed as having gluteal muscle fibrosis with hip contracture, were investigated and treated by open surgical release of fibrotic bands and physiotherapy. RESULTS: All patients improved dramatically over the subsequent weeks, and were able to sit and squat in the normal position. CONCLUSIONS: Gluteal muscle fibrosis with hip contracture is present in Iraq and more awareness is needed for early diagnosis. Surgical treatment provided excellent results. More studies are needed to delineate the aetiology of the condition.

Corrections of lower limb deformities in patients with diastrophic dysplasia.

OBJECTIVE: Accurate understanding of the cause of the underlying pathology in children with diastrophic dysplasia would help in designing targeted management of their locomotion. METHODS: Diastrophic dysplasia was diagnosed in twelve patients (nine girls and three boys; age range 1-14 years), all of whom presented with small stature and apparent short extremities. Club foot (mostly talipes equinovarus) was the most frequent and consistent abnormality. Concomitant abnormalities such as hip flexion contracture, flexion contractures of the knees with excessive valgus deformity and lateral patellar subluxation, were also encountered. Muscle ultrasound and muscle magnetic resonance imaging imaging showed no myopathic changes and muscle biopsies and the respiratory chain were normal. Serum choline kinase and plasma lactate concentrations were normal. RESULTS: Surgical correction of the foot and ankle in patients with diastrophic dysplasia is extremely difficult because of the markedly distorted anatomy. In all of these children, plantigrade foot was achieved along with the improved function of the locomotor system. Mutations of the diastrophic dysplasia sulfate transporter (also known as solute carrier family 26 member 2) were encountered. CONCLUSION: Arthrogryposis multiplex is the usual terminology used to describe the abnormality in infants with multiple contractures. Diligent orthopaedic care should be provided based on an accurate understanding of the associated syndromes in such children.

Clinical and radiographic evaluation of sagittal imbalance: a new radiographic assessment.

In this article, we describe a case series study involving a new radiologic evaluation of sagittal imbalance. We review the current radiologic assessment of sagittal imbalance and introduce a new radiologic evaluation that helps in ruling out hip flexion contracture as the primary cause of sagittal imbalance and the type and level of spinal osteotomy required to regain sagittal balance. Sagittal imbalance is important in spinal deformity assessment. Studies have confirmed that overall clinical outcomes and patient satisfaction with surgery were best in cases that resulted in an increase in lumbar lordosis. For this study, radiologic assessment of sagittal imbalance was conducted on a long, 14 × 51-inch upright lateral plain radiograph that included the proximal femur and the entire spine. The radiograph was taken with the arms at 45° forward flexion and the hips and knees fully extended. The femoral axis line was drawn and extended cephalad. The C7 offset, the perpendicular distance between the femoral axis line and the center of C7, represented the degree of sagittal imbalance. The angle between the femoral axis line and a line extending from the center of C7 to the vertebra at the level of the proposed osteotomy--the Seattle angle--predicted how much correction was required to bring the C7 plumb in line with the femoral axis and to decrease the C7 offset, thus regaining sagittal balance. The proposed method was used to evaluate 10 consecutive patients who required spinal osteotomies to regain sagittal balance. Preoperative and postoperative plain radiographs were assessed twice, at a 6-week interval, by an independent spine surgeon and a musculoskeletal radiologist. Cohen κ correlation coefficients were used to calculate intraobserver and interobserver reliability. The 2 reviewers' intraobserver reliability was excellent (κs = 0.98, 0.93). Interobserver reliability was lower but good (κ = 0.76). Inclusion of the proximal femur on the long upright lateral plain radiograph of the entire spine and identification of the relation between the femoral axis line and the center of C7 are important in evaluating sagittal imbalance. Excellent intraobserver reliability, coupled with good interobserver reliability, suggest that this new radiologic assessment method can be helpful in preoperative assessment of sagittal imbalance.

Aracnodactilia contractural congénita / Congenital contractural arachnodactyly

La aracnodactilia contractural congénita (ACC) es un trastorno del tejido conectivo debido a una mutación autosómica dominante. La persona afectada de ACC presenta múltiples expresiones clínicas, incluidas las cardiacas y, principalmente, las musculoesqueléticas. Los progresos en el control de la gestación y la accesibilidad a técnicas de reproducción asistida llevan, cada vez más, a tener que atender situaciones como el caso clínico que se presenta: una gestación gemelar bicorial biamniótica obtenida por técnica de fertilización in vitro en una mujer afectada de dicha enfermedad. Los retos diagnósticos, las alternativas terapéuticas, el pronóstico materno y neonatal y las repercusiones sociales y éticas de estos casos son temas para la reflexión(AU)

Congenital contractural arachnodactyly (CCA) is a connective tissue disorder caused by an autosomal dominant mutation. Affected individuals show multiple involvement, including cardiac and, mainly, musculoskeletal abnormalities. Because of advances in pregnancy management and access to assisted reproduction techniques, situations such as that reported in the present article will become more frequent: we describe a dichorionic diamniotic twin gestation obtained by in vitro fertilization in a woman with CCA. The diagnostic challenges, therapeutic alternatives, maternal and neonatal outcomes, and the social and ethical repercussions of these cases are discussed(AU)

Reliability of physical examination in the measurement of hip flexion contracture and correlation with gait parameters in cerebral palsy.

BACKGROUND: this study was undertaken to determine the validity and reliability of the physical examination tests commonly used to measure hip flexion contracture in patients with cerebral palsy who are able to walk. METHODS: thirty-six consecutive patients (twenty-two male and fourteen female patients), with a mean age (and standard deviation) of 9.8 ± 3.9 years, who had cerebral palsy (level I, II, or III on the Gross Motor Function Classification System) and thirty-seven children without cerebral palsy (nineteen male and eighteen female subjects), with a mean age of 10.0 ± 3.0 years, were enrolled prospectively for this study. Hip flexion contracture was determined by three physical examination tests: the Thomas test, the prone hip extension test (the Staheli test), and the hamstring shift test. Three-dimensional gait analysis was performed in all subjects. The interobserver reliabilities of the three physical examination tests were determined with use of three observers. Convergent validity was assessed by evaluating the relationships between the findings on physical examination and kinematic and kinetic gait variables (maximum hip extension during stance and hip flexor index) and three-dimensional modeled psoas lengths. RESULTS: the Thomas test showed the highest intraclass correlation coefficient (0.501 in patients and 0.207 in controls) and the smallest mean absolute difference (5.8° in patients and 1.2° in controls). The Staheli test was found to be the most valid method in the patient group (r = 0.568 with hip flexor index), whereas the Thomas test was the most valid in the control group (r = 0.526 with maximum hip extension in stance, and r = 0.532 with the hip flexor index). The hamstring shift test had the lowest intraclass correlation coefficient and the lowest convergent validity. CONCLUSIONS: while the Thomas test showed the highest intraclass correlation coefficient and the smallest mean absolute difference, the Staheli test was the most valid method for detecting hip flexion contractures in patients with cerebral palsy. Although the Staheli test cannot be used for intraoperative assessment, we recommend that this test be included in preoperative physical examinations to determine the role of a hip flexion contracture in the abnormal gait of patients with cerebral palsy.

Classification of gluteal muscle contracture in children and outcome of different treatments.

BACKGROUND: Gluteal muscle contracture (GMC) is a clinical syndrome due to multiple etiologies in which hip movements may be severely limited. The aim of this study was to propose a detailed classification of GMC and evaluate the statistical association between outcomes of different management and patient conditions. METHODS: One hundred fifty-eight patients, who were treated between January 1995 and December 2004, were reviewed at a mean duration of follow-up of 4.8 years. Statistical analyses were performed using X2 and Fisher's exact tests. RESULTS: Non-operative management (NOM), as a primary treatment, was effective in 19 of 49 patients (38.8%), while operative management was effective in all 129 patients, with an excellence rating of 83.7% (108/129). The outcome of NOM in level I patients was significantly higher than in level II and III patients (P < 0.05). The results of NOM and operative management in the child group were better than the adolescent group (P < 0.05). Complications in level III were more than in level II. CONCLUSION: NOM was more effective in level I patients than in level II and III patients. Operative management was effective in patients at all levels, with no statistical differences between levels or types. We recommend NOM as primary treatment for level I patients and operative management for level II and III patients. Either NOM or operative management should be carried out as early as possible.

[Psoas abscess with hip contracture in a patient with Crohn's disease].

A psoas abscess (PA) is a rare clinical entity but is potentially serious condition which presents diagnostic and therapeutic challenges. The diagnosis is frequently delayed due to its variable and nonspecific features and occult clinical course. The delay in diagnosis and treatment of PA is the major poor prognostic factor. We describe herein a case of the sterile psoas abscess complicating Cronh's disease which presented as hip flexion contracture. A 29-year-old man, at remission stage of CD involving ileocolic segment, was admitted due to pain from hip contracture. He had no bloody diarrhea and no abdominal pain. PA was confirmed by abdominal ultrasound. PA with hip contracture was completely treated with surgical excision, irrigation, drainage, and antibiotics. PA was sterile and there was no evidence of a fistulous communication from the bowel. Once suspected, aggressive diagnostic work up and definitive operative intervention is needed.

[Primary abductor hip contracture as diagnostic, prognostic and therapeutic problem in child hip pathology].

Coxa obliqua represents a special functional entity in the pathology of the child hip. Authors have confirmed the results of S.L. Weissman and B. Strinovic which claimed that the abductor contracture of the hip was a primary congenital condition that developed as a result of intrauterine malposition, leading later to the contralateral adductor contracture. Critical period for the development of complications was between 6 and 8 month after birth, adductor contracture might keep persisting together with the development of acetabular dysplasia, and later on with ipsilateral subluxation. This malformation has usually been diagnosed within 3 and 6 months of age. It could be connected with some other signs of malposition, such as plagiocephaly, torticollis or infantile thoracic C scoliosis. For the diagnosis of coxa obliqua, the examination of hips in the prone position was very important and the ultrasonic and radiological examinations were crucial. The applied treatment used to be exclusively physical rehabilitation. Wide diapering has been contraindicated. In this study, we included 2,500 newborns, 1,300 boys and 1,200 girls (5,000 hips). In 22 cases of coxa obliqua (10 per thousand), the excellent results were obtained in 96% of cases. In two unsuccessfully treated cases, a contralateral dysplasia developed, and in one untreated, subluxation. The authors are advocating a systematic and early detection and treatment of the primary coxa obliqua.

[Rotation-abduction contracture of the hip joint]. / Przykurcz rotacyjno-odwiedzeniowy stawu biodrowego.

The paper presents the rotation-abduction contracture of the hip, a problem of growing magnitude in recent years. The anatomy of the hip joint, the perils related to muscle physiology, the symptoms of the disease, the etiology and means of surgical treatment according to Fernandez de Valderrama and Esteve de Miguel are discussed. The results of surgical treatment of 12 patients at the Orthopedic Department of Wroclaw. The presented procedure has been used in our center since 1993, and the results encourage further use of this technique.

Retracción de miembros inferiores en un paciente con hipertiroidismo / Retraction of lower limbs in a patient with hyperthyroidism

We report a 47 years old woman with hyperthyroidism that had a severe tendinous retraction of hips and knees that subsided with propylthiouracil treatment. Electrodiagnosis showed myopathic alterations and muscle strength was moderately reduced. The authors did not find references of a similar condition in patients with hyperthyroidism

Factors affecting appearance patterns of hip-flexion contractures and their effects on postural and gait abnormalities.

Hip flexion contractures accompanying various orthopedic and neurologic conditions not only limits the physical activities of the patients but also distorts their postures and gait patterns. The purposes of this study were to characterize the appearance patterns of flexion contracture at the hip joints and to elucidate how this disability affects their postural and gait abnormalities. Seventy-eight patients (mean age of 68.1 +/- 10.5 years) with hemiplegia, femoral neck fractures, osteoarthritis of the hip and other conditions causing hip flexion contractures were studied. The presence and degree of hip flexion contracture were estimated in the supine position using the Thomas maneuver with a goniometer. Relationship between appearance patterns and 12-survey variables was also analyzed statistically. As a result, it was revealed that whether lack of mobility caused by hip flexion contracture was compensated for by pelvic tilt an an increase of lumbar lordosis or not was affected by four factors. It was also revealed that whether it appeared unilaterally or bilaterally was affected by five factors. In addition, some postural and gait abnormalities caused by hip flexion contracture were observed in many patients. These results suggest that clinical pictures of the patient's posture and gait abnormality depend on his ability to regulate the position of the trunk and knees as well as the mobility of his spine.

Age and migration percentage as risk factors for progression in spastic hip disease.

Age and migration percentage were evaluated as risk factors for the progression of spastic hip subluxation in patients with cerebral palsy. Three age-groups were defined: group 1 (two to eight years), group 2 (nine to 18 years), and group 3 (over 18 years). Four subluxation groups were defined by migration percentage: group A (< 30 per cent), group B (30 to 60 per cent), group C (60 to 90 per cent), and group D (> 90 per cent). The risk of progression was the same in groups 1A and 2A, and both of these were higher than the risk in group 3A. All group B hips had similar risks for progression, and all group C hips progressed to group D (> 90 per cent migration percentage). Groups 1A, 1B, 2A, 2B and 3B hips need close radiographic follow-up to detect progressive subluxation. All group C hips required surgical treatment for progression to dislocation to be avoided.

Hip flexion contracture in cerebral palsy. The association between clinical and radiologic measurement methods.

Hip flexion contracture was examined in 51 spastic cerebral palsy patients by three clinical methods and two radiologic methods. An extremely low association was found between the clinical and radiologic methods with no particular method, clinical or radiologic, showing a higher association. The method of clinical examination should be chosen by convenience. Radiologic measurements by the methods used did not add useful information.

[Report on the diagnosis and treatment of muscular contracture. The Ad Hoc Committee of the Japanese Orthopaedic Association of Muscular Contracture].

Muscular contracture due to repeated intramuscular injections raised urgent questions from the medico-legal standpoint when a large number of children with quadriceps contracture was found in Yamanashi Prefecture in 1973. In 1975, the Japanese Orthopaedic Association formed an Ad Hoc Committee on Muscular Contracture to investigate the diagnosis and treatment of this particular condition. Since then, the Committee has studied the symptomatology, diagnosis, natural history, orthotic and operative treatment of quadriceps, deltoideus and gluteus contractures. The results have been reported annually to the Japanese Orthopaedic Association, and guidelines for diagnosis and treatment have been made available to its members. Quadriceps contracture can be classified into three types: the rectus femoris, vastus, and mixed types. The rectus femoris type represents 80 to 90 per cent of cases with quadriceps contracture, while the vastus type is quite rare. In both the rectus femoris and mixed types, operative treatment is suggested when the knee flexion is limited to 30 degrees or less in the prone position. Transverse division of the rectus femoris at the muscle belly is the standard operative procedure recommended for the rectus femoris type and gives very satisfactory results in most cases. In the mixed type, an additional division of the scarred portion of the vasti is needed. The ideal age for such procedures is near or after the end of growth. The vastus type is difficult to cure, but to improve the condition to a certain extent an operation is suggested when the knee flexion is limited to 45 degrees or less in the supine position. The operative procedure recommended is either release of the affected vasti at their insertion to the patella or Z-lengthening of the common tendon of the quadriceps. In deltoideus contracture, the Committee proposed a scoring system for evaluating the severity with the grade of abduction contracture and the opposite shoulder test as parameters. A score of 5 points or more indicates operative treatment. The operative procedure recommended is release of both the acromial part and the anterior fibers of the spinal part of the deltoideus. The ideal age for this procedure is 12 years or older. A dent produced by the operation distal to the acromion, however, has to be regarded as a cosmetic complication. To avoid this complication, advancement of the severed fibers of the deltoideus from the scapular spine to the acromion is needed. Such an advancement procedure is suitable for children of 14 or 15 years of age and leaves the natural round contour of the shoulder intact.(ABSTRACT TRUNCATED AT 400 WORDS)