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.

[Lower extremity deformities as an obstacle in rehabilitation of meningomyelocele patients--pathogenesis and principles of treatment]. / Znieksztalcenia konczyn dolnych jako przeszkoda w usprawnianiu chorych z przepuklina oponowo-rdzeniowa--mechanizm powstawania i zasady leczenia.

The fate of 89 patients with meningomyelocele operated at the Institute of Orthopedics and Rehabilitation in Poznan between 1970 and 1989 due to paretic deformities of lower extremities has been traced by the authors. Deformities prevented nursing, standing or ambulating; their type and results of treatment have been related to the level of neurosegmental lesion. Modified Sharrard's classification served to group the patients. The level of lesion established during lower extremities muscles testing has been verified after neurological examination supplemented with electrophysiological tests: sensory response within L3-S2 dermatomes, afferent conduction velocity of the peroneal nerve and selected muscles of lower extremity electromyogram. Deformities due to inadequate nursing (hip and knee contractures and equinus foot) were the main obstacle in the rehabilitation in patients with spinal Th12-L2 lesion. In patients with L3-L5 lesion hip contractures were accompanied by dislocation or subluxation of the hip due to muscular imbalance. Knee contracture was less frequent in this group and foot deformities were diverse. Surgical correction of paretic deformity of the hip was the last stage of management designed to promote rehabilitation, following previous foot and knee surgery. In patients with Th12-L2 lesion recurrence of contractures made standing and walking impossible. In patients with L3-L5 neurosegmental lesion surgery for paretic dislocation or subluxation of the hip inclusive of open reduction, varus-derotation osteotomy of the proximal femur, transiliac osteotomy and iliopsoas transfer to the greater trochanter according to Mustard resulted in stable hip. Seventy percent of patients with L3-L4 lesion and all patients with L5 lesion profited from hip surgery with reduced orthotic use and effective gait.

[Apparatus correction of contractures of the joints of the lower limbs in patients with infantile cerebral palsy]. / Apparatnaia korrektsiia kontraktur v sustavakh nizhnikh konechnostei u bol'nykh detskim tserebral'nym paralichom.

The method of treatment with the application of compression-distraction apparatus is described. An analysis of remote results of the treatment of 57 patients is given.

Management of hip contractures and dislocations in arthrogryposis.

Arthrogryposis represents a group of heterogeneous disorders, characterized by contractures of multiple joints at birth. Involvement of the hip is very common (55-90% of patients) ranging from soft tissue contractures to subluxation and dislocation. Isolated contracture of the hip can usually be managed conservatively: compensative mechanisms and contractures of other joints should be evaluated before planning surgery. For unilateral dislocations, open reduction is indicated to provide a level pelvis, even though the risk of stiffness, avascular necrosis and redislocation is significant. Indications for surgical reduction of bilateral dislocations are more controversial: an adequate evaluation of ambulatory potential of the child (muscular weakness, involvement of upper extremities, etc.) and of stiffness of the hips is suggested. An extensive and long-lasting programme of bracing, physiotherapy and multiple surgery may lead to some measure of functional ambulation in most cases, but high need for surgery and considerable risk of complications must be considered. This paper summarizes problems and principles of treatment for hip contractures and dislocations in arthrogryposis and provides a review of the current literature.

Strategies of hip management in neuromuscular disorders: Duchenne Muscular Dystrophy, Spinal Muscular Atrophy, Charcot-Marie-Tooth Disease and Arthrogryposis Multiplex Congenita.

Joint contractures, subluxation and dislocation are common problem in children with neuromuscular disorders. Medical, surgical and rehabilitative approaches can be used to maintain patient function and comfort. Contracture release, hip dysplasia correction and procedures to address or prevent hip subluxation or dislocation, are not always necessary since patients can be asymptomatic and surgical treatment will not always be successful in maintaining a reduced hip. In fact, controversy surrounds the management of hip disorder in children with Duchenne Muscular Dystrophy, Spinal Muscular Atrophy, Charcot-Marie-Tooth Disease and Arthrogryposis Multiplex Congenita. Patients with neuromuscular disorders also frequently develop a progressive scoliosis with pelvic obliquity which may affect sitting balance and become painful. Most subluxations and dislocations have the tendency to occur on the high side of a tilted pelvis. Spinal stabilisation is sometimes necessary to improve the pelvic tilt and to prevent further increase. The present article provides an overview of the current strategies of hip management in neuromuscular disorders.

[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.

[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)

Flexion contractures of the knee following poliomyelitis.

Contractures of the knee after poliomyelitis are common in children in developing countries and treatment, particularly that of severe contractures, presents a surgical challenge. This paper describes a new method for correcting contractures of the knee. Mild contractures need manipulation only and a plaster cast. Moderate contractures are treated by a partial soft-tissue release of the hamstrings and fascia lata followed by gradual stretching of the remaining soft-tissues by manipulation and plaster. Where the contracture is severe, skeletal traction is used through Steinmans pins inserted into the tibia and os calcis. One hundred and thirty-six knees with varying degrees of contracture were treated by these methods. Full correction was achieved and then maintained by plaster immobilisation, physiotherapy and calipers. This prevented recurrence during an average follow-up period of two and a half years. The severity of the contracture of the knee was in direct proportion to the severity of associated flexion-abduction contractures at the hip and equinus deformity at the ankle, the degree of muscle imbalance. All of the contractures of the hip and some of the ankle (46.8%) needed simultaneous operative correction. The basic method is technically simple, requires no special equipment and the results recommend its use particularly in developing countries.

[Contractures and growth disturbances in the hip and pelvis as the cause of "idiopathic scoliosis". Biomechanical considerations]. / Przykurcze i zaburzenia rosniecia w obrebie biodra i miednicy przyczyna rozwoju tzw. "skolioz idiopatycznych". Rozwazania biomechaniczne.

Author's own observations on etiology of "idiopathic scoliosis" in children and adolescents are presented. Abduction or flexion-abduction contracture of the hip, mainly right one, is the chief cause of "idiopathic scoliosis". Scoliosis is the final deformity in the chain of malformations commencing in newborns and infants, known as "contracture syndrome". This condition is described by many authors, Mau and Green-Griffin were the first ones. Adduction contracture of the left hip leads to secondary dysplasia of this joint. Coexisting abduction contracture of the right hip is usually neglected. Insufficient adduction in the right hip in extension causes functional elongation of the right extremity and oblique positioning of the pelvis, thus initiating left hand side lumbar, thoraco-lumbar or lumbo-sacral scoliosis. As the next step thoracic scoliosis develops. Early and late clinical and radiographic symptoms are presented, prophylactics and treatment is discussed.

The hip in arthrogryposis multiplex congenita.

The hip is involved in up to 80% of individuals with a diagnosis of arthrogryposis multiplex congenita. The hip deformity consists of contracture with or without dislocation. Isolated contracture can usually be treated conservatively by manipulation and splinting, only occasionally requiring operative intervention. Dislocation is as frequently bilateral as unilateral. Bilateral hip dislocations are best left unreduced; only accompanying contractures should be treated. The unilateral dislocation should be treated aggressively, because persistent dislocation will give rise to pelvic obliquity and scoliosis. Open reduction is always necessary.

Extension-abduction contracture of the spastic hip.

Patients with cerebral palsy and fixed hip extension are often unable to sit and therefore lose social and educational opportunities. At Texas Scottish Rite Hospital (Dallas, TX, U.S.A.), 29 patients had hip extension-abduction contractures. Eleven patients with mild involvement were managed with physical therapy. Six patients had moderate involvement and required wheelchair modification to maintain sitting. Twelve patients demonstrated severe contractures that required major soft tissue releases and often femoral shortening osteotomies to regain flexion. Patients with athetosis or rigidity were identified as those most likely to develop extension-abduction contractures either spontaneously or following adductor releases.