David A. Yngve

Management of femoral shaft fractures in the adolescent.

Forty-four patients (45 fractures) with open physes (age range 11–16 years) underwent treatment for femoral shaft fractures. Seven malunions occurred in the 24 fractures in the nonoperative group; none occurred in the 21 fractures treated by intramedullary nailing. Hospital stay was significantly shorter in the operatively treated patients. There was no premature growth arrest in the surgical group.

Vulpius and Z-lengthening.

An evaluation of ankle function in gait after 22 Vulpius lengthenings of the gastrocnemius fascia and 27 Z-lengthenings of the Achilles tendon was performed in 33 ambulatory cerebral palsy patients. Simultaneous hip or knee surgeries or both were performed in most instances. Gait analysis including ankle motion, moment, and power data was obtained before surgery and approximately 1 year after. The ankle moments were improved and approached normal in the majority of cases in each group. There were no significant differences between the Vulpius and Z-lengthening groups at follow-up in any of the parameters. There were significant differences between the initial and follow-up measurements of each group. The Vulpius group showed a notable presence of abnormal midstance work initially and had a significant decrease at follow-up. The Z-lengthening group showed a notable presence of equinus and a notable lack of push-off work initially and had a significant decrease in equinus and a significant increase in push-off work at follow-up. Each procedure appears to give satisfactory results because the follow-up results were similar.

Rectus and hamstring surgery in cerebral palsy: A gait analysis study of results by functional ambulation level

The purpose of this study is to determine if children more severely involved with cerebral palsy respond as well to rectus transfer and hamstring surgery as those with less severe involvement. Ninety-nine children were classified as independent community ambulators, crutch/walker-dependent community ambulators, or household/exercise ambulators. Maximum knee extension in stance and total range of knee motion in gait increased following surgery in all groups. Peak knee flexion in swing was maintained in the independent group only, but timing of knee flexion in swing improved in all groups. All groups showed increases in stride length, and the household/exercise group also showed an increase in walking speed. Four of 39 crutch/walker-dependent community ambulators and 13 of 21 household/exercise ambulators progressed to the next higher functional ambulation group.

Spinal cord injury without osseous spine fracture.

Sixteen patients with spinal cord injury without osseous spine fracture and 55 patients with spinal cord injury with osseous spine fracture aged from birth through 18 years were studied. Those without osseous fracture were younger (mean age 6 years) than were those with osseous fracture (mean age 16 years). Extravasation of myelographic dye from the spinal canal was a poor prognostic sign. All three in the group with this finding without osseous fracture had complete spinal cord lesions. Those without osseous fracture should be followed for the development of late spinal deformity that may require orthotic support or surgical stabilization.

The reciprocating gait orthosis in myelomeningocele

Seventeen patients with myelomeningocele were fitted with a device that reciprocally controls hip flexion and extension in an attempt to improve ambulatory ability. To evaluate the function of the reciprocating mechanism, the orthosis was tested in three configurations. With the reciprocating mechanism functioning at the hips, five of eight patients ambulated faster than in other configurations. With the mechanism released for free hip joint motion, five of eight patients ambulated slower or not at all. With the hip joints locked, six of eight patients ambulated more slowly than with the reciprocating mechanism functioning. Two were faster with a swing-through gait. However, 11 of 12 independent ambulators spontaneously chose the reciprocating gait pattern over the swing-through pattern. The reciprocating gait orthosis was used by patients with meningomyelocele from 18 months to 15 years of age. The device was most successful if strong hip flexors were present, although ambulation in a reciprocal pattern was possible for some with no active hip musculature. We believe that this orthosis is the most effective ambulatory aid for children handicapped by hip extensor weakness.

Foot-progression angle in clubfeet

Foot-progression angle was determined using the Shutrack carbon paper system for 52 feet treated by clubfoot release without wide subtalar release and 43 age-matched controls. Mean foot progression angle was -5 degrees for the clubfeet. This represented 13 degrees of inturning from the normal mean of 8 degrees. Forty-eight percent of the clubfeet had inturning greater than 2 SD from the normal mean. The causes of inturning included adductus (p = 0.005) and, in some cases, internal tibial torsion or internal femoral torsion. Varus of the foot was usually associated with inturning, but inturning was not always associated with varus.

Segmental spinal instrumentation with sublaminar wires. A critical appraisal.

Fifty-eight patients who had scoliosis or kyphosis of varying etiologies were followed for a minimum of two years (average, forty-four months) after segmental spinal instrumentation using sublaminar wires. In eight (19 per cent) of the patients who had been operated on for scoliosis one or both rods broke. The average time that had elapsed before the breakage was discovered was twenty-three months. None of the patients in whom a rod had broken had had postoperative immobilization or a first-stage anterior fusion, and only one had had supplementary grafting with banked bone. Instrumentation to the pelvis was also associated with a greater incidence of broken rods. The use of supplementary grafting with banked bone or the use of postoperative immobilization significantly decreased the loss of postoperative correction. Preliminary anterior spinal fusion helped prevent breakage of rods but not loss of correction. It was concluded that postoperative immobilization and use of large amounts of supplementary bone graft lead to better results when using this implant system.

Acetabular hypertrophy in Legg-Calve-Perthes disease

Summary: Measurements from the radiographs of 65 children with unilateral Legg-Calvé-Perthes disease showed that in 61 cases, the acetabulum was larger on the affected side by a mean of 4.0 mm. The mean femoral head size was increased in 60 of 65 cases by 6.8 mm. Acetabular and femoral head overgrowth occurred in a parallel fashion with onset early in the course of the disease. Hyperemia is the most likely explanation for this joint overgrowth. Acetabular contour was evaluated in 83 hips. Nineteen of these hips exhibited the sign of acetabular bicompartmentalization. This appears to be the result of maximally active cartilage hypertrophy and lateral placement of the femoral head. Bicompartmentalization can be seen 3 months after the onset of symptoms and is a poor prognostic sign

Disorders of the sacro-iliac joint in children.

The cases of seventeen children whose ages ranged from two to eighteen years and who were treated for a disorder of a sacro-iliac joint between 1975 and 1983 were reviewed retrospectively. Thirteen children were acutely ill, with a temperature of more than 38 degrees Celsius, and four had chronic symptoms that had persisted for three weeks to one year. Pain in the hip, thigh, and buttock was the most common symptom. Of the thirteen acutely ill patients, eleven had septic arthritis of a sacro-iliac joint, while one who had ankylosing spondylitis and one who had juvenile rheumatoid arthritis had acutely painful arthritis of a sacro-iliac joint. Of the four patients who had chronic symptoms, two had septic arthritis of a sacro-iliac joint; one, ankylosing spondylitis with sacro-iliac involvement; and one, eosinophilic granuloma of the ilium. Thus, thirteen patients had septic arthritis of a sacro-iliac joint and four had some other disorder. For the seventeen children who had acute or chronic symptoms, at admission the white blood-cell count ranged from 3,500 to 26,200 per cubic millimeter (average, 11,100 per cubic millimeter) and the sedimentation rate, as determined by the Westergren technique, ranged from twenty-two to sixty-five millimeters per hour (average, fifty millimeters per hour). Twelve of the plain radiographs of the seventeen patients were negative. The initial bone scans of all seventeen patients were positive in eleven and negative in six. Of these six, five had septic arthritis and one, juvenile rheumatoid arthritis. A computed tomographic scan was performed in four patients and was positive in all of them: three had septic arthritis and one had ankylosing spondylitis. Organisms were cultured successfully from blood, from material aspirated from the sacro-iliac joint, or from stool of all thirteen patients who had sepsis. The thirteen infections responded well to appropriate antibiotics, which were administered intravenously to seven patients and first intravenously and then orally to six.

Foot progression angle after distal tibial physeal fractures

Twenty-three patients with Salter 1 or 2 fractures of the distal tibia had follow-up with footprints to assess rotational deformities. Fourteen had external rotation deformity >+2 SD of the normal mean of 5° to 6°. Eight of the 14 had the finding of physeal widening of 2 mm or more. The widening was most commonly wedge-shaped and based anteriorly. The mean foot progression angle of the fractured sides was externally rotated 14°, and the mean foot progression angle of the uninjured sides was externally rotated 10°; both exceeded the normal mean. The fractured side mean was significantly more externally rotated than the uninjured side mean. Preexisting external rotation deformity may be a risk factor for these fractures. Closed reduction with long leg bent-knee casting is justified in more than half of these patients.