Spinopelvic Compensatory Mechanisms for Reduced Hip Motion (ROM) in the Setting of Hip Osteoarthritis.

STUDY DESIGN: Retrospective review from a single institution. OBJECTIVE: To investigate the effect of hip osteoarthritis (OA) on spinopelvic compensatory mechanisms as a result of reduced hip range of motion (ROM) between sitting and standing. SUMMARY OF BACKGROUND DATA: Hip OA results in reduced hip ROM and contracture, causing pain during postural changes. Hip flexion contracture is known to reduce the ability to compensate for spinal deformity while standing; however, the effects of postural spinal alignment change between sitting and standing is not well understood. METHODS: Sit-stand radiographs of patients without prior spinal fusion or hip prosthesis were evaluated. Hip OA was graded by Kellgren-Lawrence grades and divided into low-grade (LOA; grade 0-2) and severe (SOA; grade 3 or 4) groups. Radiographic parameters evaluated were pelvic incidence (PI), pelvic tilt (PT), lumbar lordosis (LL), PI-LL, thoracic kyphosis (TK), SVA, T1-pelvic angle (TPA), T10-L2, proximal femoral shaft angle (PFSA), and hip flexion (PT change-PFSA change). Changes in sit-stand parameters were compared between LOA and SOA groups. RESULTS: 548 patients were included (LOA = 311; SOA = 237). After propensity score matching for age, body mass index, and PI, 183 LOA and 183 SOA patients were analyzed. Standing analysis demonstrated that SOA had higher SVA (31.1 vs. 21.7), lower TK (-36.2 vs. -41.1), and larger PFSA (9.1 vs. 7.4) (all p < .05). Sitting analysis demonstrated that SOA had higher PT (29.7 vs. 23.3), higher PI-LL (21.6 vs. 12.4), less LL (31.7 vs. 41.6), less TK (-33.2 vs. -38.6), and greater TPA (27.9 vs. 22.5) (all p < .05). SOA had less hip ROM from standing to sitting versus LOA (71.5 vs. 81.6) (p < .05). Therefore, SOA had more change in PT (15.2 vs. 7.3), PI-LL (20.6 vs. 13.7), LL (-21.4 vs. -13.1), and T10-L2 (-4.9 vs. -1.1) (all p < .001), allowing the femurs to change position despite reduced hip ROM. SOA had greater TPA reduction (15.1 vs. 9.6) and less PFSA change (86.7 vs. 88.8) compared with LOA (both p < .001). CONCLUSIONS: Spinopelvic compensatory mechanisms are adapted for reduced hip joint motion associated with hip OA in standing and sitting. LEVEL OF EVIDENCE: Level III.

Postural asymmetry in non-ambulant adults with cerebral palsy: a scoping review.

PURPOSE: Non-ambulant adults with cerebral palsy are vulnerable to development of postural asymmetry and associated complications. The primary aim of this scoping review was to identify postural deformities in non-ambulant adults with cerebral palsy. MATERIALS AND METHODS: Comprehensive searches were undertaken in EMBASE, CINAHL, AMED, Cochrane, Psych INFO, and Joanna Briggs (1986-Jan 2017), supplemented by hand searching. Two reviewers independently extracted data using a customised tool focusing on study design, participant characteristics, postural descriptors, measurement tools, and interventions. RESULTS: From 2546 potential records, 17 studies were included. Variability in populations, reporting methodology, and measurement systems was evident. Data suggest more than 30% of this population have hip migration percentage in excess of 30%, more than 75% experience "scoliosis", and more than 40% demonstrate pelvic obliquity. Estimates ranged from 14% to 100% hip and 32% to 87% knee contracture incidence. Conservative interventions were infrequently and poorly described. CONCLUSION: Many non-ambulant adults with cerebral palsy experience postural asymmetry associated with windswept hips, scoliosis, pelvic obliquity, and limb contracture. Options for non-radiographic monitoring of postural asymmetry should be identified, and conservative interventions formally were evaluated in this population. Implications for rehabilitation The common postural asymmetries of windswept hips, scoliosis, pelvic obliquity, and limb contracture require standardised clinical measurement. Radiography is most commonly used to monitor postural asymmetry in this population, but standardised positioning is not applied and may not be feasible indicating a need for alternate methods and rigorous documentation. The Posture and Postural Ability Scale may be considered for use in the management of body shape in adults with CP.

Sustained hip flexion contracture after femoral lengthening in patients with achondroplasia.

BACKGROUND: Hip flexion contracture often occurs after femoral lengthening in patients with achondroplasia, but few studies have investigated its development in these patients. The purpose of this study was to analyze sustained hip flexion contracture in achondroplasia patients who underwent femoral lengthening and to identify contributing factors. METHODS: This study included 34 patients with achondroplasia who underwent femoral lengthening (mean age at operation, 11.1 years). Sustained hip flexion was defined as flexion contracture lasting > 6 months postoperatively despite physiotherapy. Demographic data, spinopelvic parameters (pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis, and sagittal vertical axis), and quantitative assessments of femoral lengthening were investigated. The associations among these factors and the development of sustained hip flexion contracture were assessed. RESULTS: Sustained hip flexion contracture developed in 13 (38%) of 34 achondroplasia patients after femoral lengthening. Eight (62%) of these 13 patients concomitantly exhibited limitation of knee flexion. Excessive femoral lengthening (odds ratio [OR], 1.450; 95% confidence interval [CI], 1.064 to 1.975; p = 0.019) and forward sagittal vertical axis tilt (OR, 1.062; 95% CI, 1.001 to 1.127; p = 0.047) contributed to sustained hip flexion contracture. CONCLUSIONS: Sustained hip flexion contracture frequently occurs after femoral lengthening in achondroplasia patients. Both excessive femoral lengthening and preoperative forward SVA tilt may contribute to the development of sustained hip flexion contracture in these patients.

Lower extremity joint contracture according to ambulatory status in children with Duchenne muscular dystrophy.

BACKGROUND: Lower extremity joint contractures have negative effects on gait in children with Duchenne muscular dystrophy (DMD). Thus, contracture prevention is essential for maintaining a patient's functional ability and an acceptable quality of life. This study investigated hip flexion (HF), knee flexion (KF), and ankle joint plantar flexion (APF) contractures among male patients with DMD, based on the patients' ambulatory status. Differences in major joint contractures, based on passive stretching exercise participation, were also investigated. METHODS: A total of 128 boys with DMD, followed at the DMD clinic of a tertiary care hospital, were included in this cross-sectional study. The passive ranges-of-motion of the hip, knee, and ankle joints were measured, in the sagittal plane, using a goniometer. The Vignos Scale was used to grade ambulatory function. Boys with DMD who performed stretching exercises for more than 5 min/session, > 3 sessions/week, were classified into the stretching group. RESULTS: The HF (23.5o), KF (43.5o), and APF (34.5o) contracture angles in the non-ambulatory group were more severe than those in the ambulatory group. APF contractures (41 patients, 52.6%) were more frequently observed early, even within the ambulatory period, than were hip (8 patients, 10.3%), and knee joint (17 patients, 21.8%) contractures. Passive stretching exercises > 3 sessions/week were not associated with the degree of lower extremity joint contractures in the ambulatory or non-ambulatory group. CONCLUSION: HF, KF, and APF contractures are more common and severe when there is deterioration of ambulatory function. Stretching exercises alone are unlikely to prevent lower extremity joint contractures.

Prone Position-Induced Quadriceps Transcranial Motor Evoked Potentials Signal Loss-A Case Report.

BACKGROUND: Transcranial motor evoked potential (TcMEP) is widely used intraoperatively to monitor spinal cord and nerve root function. To our knowledge, there is no report regarding TcMEP signal loss purely caused by patient positioning during the spinal procedure. PURPOSE: The objective of this article is to report an intraoperative TcMEP signal loss of a patient with fixed sagittal imbalance posture along with mild hip contractures. STUDY DESIGN: A retrospective case report. METHODS: A 57-year-old man had fixed sagittal imbalance and flexed hip contractures. For a reconstruction surgery of T10 to the sacrum/ilium and L5 pedicle subtraction osteotomy (PSO), he was put in a prone position on a Jackson table. In order to accommodate his fixed hip flexion contracture, thigh pads were not used and pillows were placed under his bilateral thighs for cushioning. TcMEPs were used to assess lumbar nerve root function. Ten minutes after incision, bilateral vastus medialis TcMEPs were lost during spine exposure whereas all other data remained normal at baseline. The bilateral lower extremities were repositioned, with the knees flexed into a sling position to increase hip flexion. Five minutes after repositioning, the bilateral vastus medialis TcMEPs gradually improved and maintained baseline amplitude during the remainder of the surgery. RESULTS: No muscle weakness was detected immediately after surgery. The patient was discharged day 6 postoperatively with markedly improved posture and alignment. CONCLUSION: Insufficient hip flexion in patients with fixed sagittal imbalance and hip flexion contractures may cause TcMEP signal changes in the quadriceps response. TcMEP monitoring of bilateral lower extremities is highly recommended for patients with sagittal imbalance and hip contractures, with consideration for lower extremity repositioning when data degradation does not correlate with the actual spinal procedure being performed.

Reorientational Proximal Femoral Osteotomies for Arthrogrypotic Hip Contractures.

BACKGROUND: Severe hip contractures in arthrogrypsosis are multiplanar, which can preclude or can greatly complicate sitting and ambulation. The reorientational osteotomy at the intertrochanteric level preserves preoperative hip motion but moves it to a more functional domain. We retrospectively compared preoperative and postoperative hip motion and evaluated the ambulatory abilities of patients who underwent the procedure. METHODS: Since 2008, 65 patients with arthrogryposis had 119 reorientational proximal femoral osteotomies with a minimum follow-up of 2 years. The mean patient age at the time of the surgical procedure was 48 months. An intertrochanteric wedge osteotomy aligned the femoral shaft with the body axis, leaving the hip joint in its preexisting position. A cannulated hip blade plate was used for fixation. Hip motions were recorded preoperatively, at implant removal, and at the time of the latest follow-up, as was ambulatory ability. RESULTS: Eighty-one hips had a mean flexion contracture of 52° preoperatively, which improved by 35°; 84 hips with a mean preoperative adduction of -20° improved by 42°; 101 hips with a mean preoperative internal rotation of -16° improved by 35° (p < 0.0001 for all). The flexion-extension total arc of motion for the 119 hips improved by 13° (p < 0.0001). Only 11 of 94 hips that preoperatively flexed ≥90° did not do so postoperatively, but none of the patients reported seating difficulties and one of the patients had already regained hip flexion of >90° by a soft-tissue release. At a mean follow-up of 40 months, 36 patients were independently ambulatory and 20 patients were walker-dependent. CONCLUSIONS: Children with arthrogryposis often have the potential for ambulation if the limb positioning can be optimized. The reorientational hip osteotomy corrects the hip contractures by altering the range of motion but not the total arc of motion. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A three-year follow-up study of the development of joint contractures in 131 patients with systemic sclerosis.

OBJECTIVES: To analyse the correlation between the number of joint-contractures and other major clinical findings in a follow-up study of 131 patients with systemic sclerosis (SSc). METHODS: The range of motion of joints (ROM), HAQ-DI, and the major clinical characteristics were assessed. RESULTS: A high frequency of contractures (ROM<75% of the normal) were present at baseline in small joints of the hand (82%), wrists (75%), and shoulders (50%). ROM of the dominant side hand was significantly more decreased compared to the non-dominant side. The number of the upper extremity contractures correlated positively with ESR (p<0.01), CRP (p<0.01), HAQ-DI (p<0.01), and negatively with forced vital capacity (FVC) (p<0.05). The number of contractures was not significantly different in cases with early (≤ 4 years) and late disease duration in both the limited and diffuse subgroups. During the three-year follow-up period, an increase in the number of joint contractures (ROM<75%) was associated with an increase of ESR, modified Rodnan's skin score, and the European Scleroderma Study Group Activity Index by multiple linear regression analysis. Univariate analysis over a six-year period demonstrated poor outcome in patients with more than ten contractures, or more than four contractures of unilateral hand-joints. CONCLUSIONS: Contractures predominantly develop during the early years following disease onset in both SSc subgroups. Inflammation and skin-involvement are significant contributing factors for the development of contractures. The dominant hand may be more pronouncedly impaired compared to the non-dominant side. A high number of joint-contractures might be an unfavourable prognostic factor in SSc.

Percutaneous Adductor Release in Nonambulant Children with Cerebral Palsy.

INTRODUCTION: Adductor spasticity at hips is the main barrier in functional activities and rehabilitation of spastic cerebral palsy patients. The aim of this study is to evaluate the results of percutaneous adductor release under general anaesthesia. METHODS: From July 2005 to July 2010, 64 hips in 32 patients (19 males and 13 females) were recruited from outpatient department having adductor contracture at hips in cerebral palsy children. All children were operated under general anaesthesia. All children were followed for twenty-four months. The clinical results were evaluated radiologically, including measurement of CE- angle, AC-index and femoral head coverage and in terms of activity level of children. RESULTS: Of the thirty-two children, twenty-eight showed marked and immediate improvement. None of our children was functionally worse at follow-up. The CE-angle and femoral head coverage did not change significantly. The AC-index improved significantly (P = 0.01).The results were excellent in 12.5% children, good in 50%, fair in 25% and poor in 12.5%. CONCLUSIONS: Bilateral mini-invasive adductor release can be an effective treatment for children suffering from adductor contracture refractory to nonoperative management and early adductor release can prevent subluxation and possibly the need for future bony procedure on the proximal femur and pelvis.

Pathological trunk motion during walking in children with amyoplasia: is it caused by muscular weakness or joint contractures?

The aim was to investigate the causes for pathological trunk movements during gait in children with Amyoplasia. Eighteen children with Amyoplasia were compared with 18 typically developed children. Three-dimensional motions of pelvis, thorax and spine during gait were analyzed. Excessive trunk movements were defined as being above 4 standard deviations of those of typically developed children. Clinical examination of active strength and passive range of motion of the hip, knee and ankle joints were correlated to the parameter that showed the greatest prevalence of pathological trunk motion. The greatest prevalence of 56% was seen for thorax obliquity range during walking. The spine angles showed the lowest deviations from typically developed children. Significant correlations (p<0.001) between thorax obliquity range and clinical parameters were found for passive hip extension, hip flexion, hip abduction and active hip extension, hip flexion and ankle dorsiflexion strength. The highest correlation coefficients were found for passive hip flexion and active hip flexion strength of rho=-0.73 and rho=-0.69 respectively. Excessive thorax obliquity during gait in children with Amyoplasia could be mainly caused by reduced strength and mobility of the hip. Therefore both mobility and strength of the hip are equally important and should be increased in the therapy to improve gait in children with Amyoplasia.

Mucopolysaccharidoses and other lysosomal storage diseases.

Mucopolysaccharidosis and other lysosomal storage diseases are rare, chronic, and progressive inherited diseases caused by a deficit of lysosomal enzymes. Patients are affected by a wide variety of symptoms. For some lysosomal storage diseases, effective treatments to arrest disease progression, or slow the pathologic process, and increase patient life expectancy are available or being developed. Timely diagnosis is crucial. Rheumatologists, orthopedics, and neurologists are commonly consulted due to unspecific musculoskeletal signs and symptoms. Pain, stiffness, contractures of joints in absence of clinical signs of inflammation, bone pain or abnormalities, osteopenia, osteonecrosis, secondary osteoarthritis or hip dysplasia are the alerting symptoms that should induce suspicion of a lysosomal storage disease.

Predicting the outcome of intramuscular psoas lengthening in children with cerebral palsy using preoperative gait data and the random forest algorithm.

This study used the random forest algorithm to predict outcomes of intramuscular psoas lengthening as part of a single event multi-level surgery in patients with cerebral palsy. Data related to preoperative medical history, physical exam, and instrumented three-dimensional gait analysis were extracted from a historic database in a motion analysis center. Data from 800 limbs of patients with diplegic cerebral palsy were analyzed. An index quantifying the overall deviation in pelvic tilt and hip flexion was used to define outcome categories. The random forest algorithm was used to derive criteria that predicted the outcome of a limb. The criteria were applied to limbs that underwent psoas lengthening with outstanding results (accuracy=.78, sensitivity=.82, specificity=.73). The criteria were then validated using an extended retrospective case-control design. Case limbs met the criteria and underwent psoas lengthening. Control limbs met the criteria, but did not undergo psoas lengthening. Over-treated limbs failed the criteria and underwent psoas lengthening. Other-treated limbs failed the criteria and did not undergo psoas lengthening. The rate of good outcomes among Cases exceeded that observed among controls (82% vs. 60%, relative risk=1.37), and far exceeded that observed in Over-treated limbs (27%). Other-treated limbs had good outcomes 52% of the time. Application of the criteria in the future is estimated to increase the overall rate of good pelvis-hip outcomes from 58% to 72% among children with diplegia who undergo single-event multi-level surgery (SEMLS).

Hip flexion contracture and diminished functional outcomes in cerebral palsy.

BACKGROUND: Hip flexion contracture (HFC) in the ambulatory child with cerebral palsy (CP) may impair function and lead to deteriorations in health-related quality of life. Furthermore, increasing HFC may lead to increasing disability. However, the association between passive range of motion and the measures of function and well-being is unclear. This study was designed to determine whether increasing HFC is associated with functional outcome. METHODS: A total of 181 children, with an average age of 14.0 ± 10.2 years, were evaluated as part of a multicenter prospective data collection of patients with ambulatory CP. Measurements of HFC were recorded, and patients were evaluated using walking score from Gillette Functional Assessment Questionnaire (FAQ), Gross Motor Function Measure (GMFM), and the Pediatric Outcome Data Collection Instrument (PODCI). Patients were grouped on the basis of severity of HFC: group A, 0 to 14 degrees; group B, 15 to 29 degrees; and group C ≥ 30 degrees. Associations were examined using the Spearman correlation. RESULTS: There was an inverse association between degree of HFC and FAQ walking score (P<0.01, ρ=-0.25). Similarly, there was an inverse association between the degree of HFC and GMFM parts D (P<0.001, ρ=-0.31) and E (P<0.001, ρ=-0.32). Lastly, the PODCI domains of global function, mobility, and physical function also showed an inverse association with degree of HFC (P<0.001, ρ=-0.24). CONCLUSIONS: As surgeons treating children with CP, we often rely on joint measurements as an indirect measure of function. This study of children with ambulatory CP suggests that increased HFC from the physician's perspective is associated with deterioration in function from a patient and a therapist's perspective. LEVEL OF EVIDENCE: Level II, prospective study.

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)

Total hip arthroplasty in a patient with arthrogryphosis and an ipsilateral above knee amputation.

The authors present the case of a young man with arthrogryphosis multiplex congenita and an above knee amputation who underwent an ipsilateral total hip replacement. The unique aspects of the case and technical difficulties are highlighted. Follow-up at five years revealed an excellent clinical and radiological outcome.

Excessive hip flexion during gait in patients with static encephalopathy: an examination of contributing factors.

BACKGROUND: Excessive hip flexion in gait is thought to be associated with hip flexion contracture, but has also been associated with excessive anterior pelvic tilt, knee flexion, internal hip rotation, and muscular factors. The purpose of this study was to examine the contributors to excessive hip flexion during gait in children with cerebral palsy, with and without hip flexion contractures. METHODS: A retrospective chart review was conducted of 155 children with cerebral palsy. Potential contributors to excessive hip flexion in stance were evaluated, including static and dynamic range of motion, strength measurements, and patient factors including age, previous surgery, distribution of involvement (hemiplegia, diplegia, and quadriplegia), and Gross Motor Function Classification System level. Univariate analysis was performed using simple linear regression and analysis of variance, with appropriate post-hoc tests. All variables were then included in a stepwise linear regression using forward selection. RESULTS: Univariate analysis demonstrated a significant relationship (P<0.05) between excessive hip flexion in stance and all predictive variables except static dorsiflexion range of motion with the knee flexed and maximum dorsiflexion in stance. Results of stepwise regression revealed that 3 variables accounted for 65% of the variance: passive hip extension range of motion, average pelvic tilt during the gait cycle, and knee extension achieved in the stance phase of gait. Twenty-two of 45 (49%) exhibiting hip flexion contractures of greater than 10 degrees did not exhibit excessive hip flexion in stance phase. CONCLUSIONS: Hip extension in stance in children with static encephalopathy depends primarily on hip extension passive range of motion, the amount of pelvic tilt, and knee extension in stance phase. These 3 variables account for 65% of variance in these 155 patients, whereas other factors (age, dorsiflexion in stance, and hamstring range) each account for only 2% to 3% of the variance. Careful clinical examination, including computerized gait analysis when available, is recommended before surgical intervention to determine whether excessive hip flexion is a primary or compensatory deviation. LEVEL OF EVIDENCE: Level IV, case series.

Botulinum toxin type A in the treatment of painful adductor muscle contracture after total hip arthroplasty.

Painful adductor muscle contracture is an important cause of failure during rehabilitation following total hip arthroplasty (THA). Adductor muscle contracture may be caused by postoperative muscle retractions, adhesive capsulitis, postoperative leg-length inequalities caused by implant failure, or preexisting hip pathologies. A 34-year-old woman experienced a persistent painful contracture into the left adductor magnus muscle after THA. She had no leg-length inequalities and, according to the Medical Research Council scale (grades 0-5), muscle strength of the quadriceps was 5/5 for the right side and 3/5 for the left. The degree of functionality according to the Harris hip score (HHS) was 16/100 in the left hip. The pain level, measured with the visual analog scale (VAS), was 7/10. The patient was unable to fully adhere to the rehabilitation program and walked with a limp during the stance phase of gait. After 7 days of treatment with injections of botulinum toxin type A into the left adductor magnus muscle (dose, 150 UM) and subsequent rehabilitation, a great reduction of painful contracture was observed (VAS score, 2/10). The procedure was well tolerated and no adverse effects were noted. After 20 days, hip articular range of motion and gait had improved (HHS score, 75/100). The clinical effects of botulinum toxin type A were present at 2-month follow-up. This treatment may be a viable alternative for the management of painful adductor muscle contracture after THA, without significant side effects.

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.

Idiopathic chondrolysis treated with etanercept.

Idiopathic chondrolysis of the hip in children has been well documented in the literature. The insidious nature of the symptoms and lack of early radiographic findings and diagnostic testing often delay diagnosis. Children often report a stiff, painful hip and have an associated limp in the absence of trauma or constitutional symptoms. Despite these symptoms it remains a poorly understood diagnosis with no identifiable cause. Some have speculated an inflammatory cause, as this disease exhibits joint space narrowing, presumably due to enzymatic activity similar to juvenile rheumatoid arthritis. Despite case reports attempting traction, physical therapy, nonsteroidal anti-inflammatories, steroids, and even operative intervention, no current treatment regimen exists that offers proven appreciable benefit. We hypothesized the powerful anti-inflammatory properties of etanercept would provide symptomatic and radiographic improvement of idiopathic chondrolysis of the hip. This article presents a case of an adolescent boy with a stiff, painful left hip that failed treatment with traction, physical therapy, naproxen, and methotrexate, prior to initiating etanercept. After 1 year of daily etanercept therapy, the patient's hip motion improved in all directions and his pain completely resolved. This novel therapeutic approach offered symptomatic relief and radiographic improvement, and may provide an effective treatment strategy for this difficult disease.

Arthroscopic gluteal muscle contracture release with radiofrequency energy.

Gluteal muscle contracture is common after repeated intramuscular injections and sometimes is sufficiently debilitating to require open surgery. We asked whether arthroscopic release of gluteal muscle contracture using radiofrequency energy would decrease complications with clinically acceptable results. We retrospectively reviewed 108 patients with bilateral gluteal muscle contractures (57 males, 51 females; mean age, 23.7 years). We used inferior, anterosuperior, and posterosuperior portals. With the patient lying laterally, we developed and enlarged a potential space between the gluteal muscle group and the subcutaneous fat using blunt dissection. Under arthroscopic guidance through the inferior portal, we débrided and removed fatty tissue overlying the contractile band of the gluteal muscle group using a motorized shaver introduced through the superior portal. Radiofrequency then was introduced through the superior portal to gradually excise the contracted bands from superior to inferior. Finally, hemostasis was ensured using radiofrequency. Patients were followed a minimum of 7 months (mean, 17.4 months; range, 7-42 months). At last followup, the adduction and flexion ranges of the hip were 45.3 degrees +/- 8.7 degrees and 110.2 degrees +/- 11.9 degrees, compared with 10.4 degrees +/- 7.2 degrees and 44.8 degrees +/- 14.1 degrees before surgery. No hip abductor contracture recurred and no patient had residual hip pain or gluteal muscle wasting. We found gluteal muscle contracture could be released effectively with radiofrequency energy.