M. Mark Hoffer

Functional ambulation in patients with myelomeningocele.

The factors important in achieving good walking status in myelomeningocele include level of paraplegia, the additional anomalies of brain and kidney, the intelligence, and the home environment. In a group of fifty-six patients none of those with lesions of the thoracic level walked and all of those with lesions of the sacral level walked. In those with lesions at lumbar levels (twenty-one lower and nineteen upper) fourteen were community ambulators and five household ambulators. The other twenty-one were either wheel-chair (nineteen) or non-functional ambulators (two) and the level of paraplegia did not seem to matter nor did the extent of surgery. Some very young non-functional ambulators rose in functional level, but in most instances the trend was to deteriorate.

Ulnar nerve palsies after percutaneous cross-pinning of supracondylar fractures in children's Elbows

From 1991 to 1994, 375 supracondylar fractures had percutaneous pinning after closed or open reduction. Nineteen of these with normal preoprative neurologic examinations had postoperative ulnar nerve palsies. All but two of the 19 were followed up. These 17 patients had complete return of function. Only four of the 17 had the medial pins removed, and two others had explorations, which showed no interruption of the nerve. Many of these patients did not have complete return of function until after 4 months. From this and other studies, it is clear that ulnar nerve palsies occurring after percutaneous pinning of the supracondylar fracture usually resolve spontaneously.

Gait Analysis of the Triceps Surae in Cerebral Palsy: A Preoperative And Postoperative Clinical And Electromyographic Study

Preoperative static clinical evaluation of the spastic triceps surae often fails to indicate which of the two muscles (soleus or gastrocnemius) is the more distorted in its phasic activity during walking or in response to stretch. Gait electromyography is a method of distinguishing gastrocnemius from soleus problems. We customarily perform electromyographic studies prior to surgery. If isolated gastrocnemius phase distortion or clonus, or both, is found, a gastrocnemius recession is performed. When combined soleus and gastrocnemius problems are noted an Achilles-tendon lengthening is done.

Paralysis of the Intrinsic Muscles of the Hand Secondary to Lipoma in Guyon's Tunnel

Distal ulnar-nerve palsy has been reported secondary to occupational trauma, thromboangiitis, ganglion, and anatomical abnormalities of the ulnar tunnel. Although lipomas have been reported as the cause of sensory ulnar-tunnel syndromes, we believe this is the first isolated motor palsy withoout sensory deficit to be reported secondary to a lipoma in the ulnar tunnel.

Closed reduction and tendon transfer for treatment of dislocation of the glenohumeral joint secondary to brachial plexus birth palsy.

Dislocation of the glenohumeral joint developed, in the first few years of life, in eight children who had brachial plexus birth palsy. The palsy involved the fifth and sixth cervical nerve roots in six children and the fifth, sixth, and seventh cervical nerve roots in two. All of the children had a release of the insertions of the pectoralis major, latissimus dorsi, and teres major followed by a closed reduction of the glenohumeral joint. The latissimus dorsi and the teres major were then transferred to the rotator cuff. All of the children had a well located glenohumeral joint with at least 25 degrees (mean, 51 degrees) of external rotation and at least 135 degrees (mean, 164 degrees) of abduction at the latest follow-up examination, at least two years postoperatively. Strength in abduction increased at least one grade, and strength in external rotation increased at least two grades. The improved motion and strength allowed the children to place the hands more effectively above the head and helped them to perform activities of daily living easily.

Posterior Tibial Tendon Transfer: A Review of the Literature and Analysis of 74 Procedures

At Rancho Los Amigos Hospital on the Childrens Orthopedic Service, 43 patients underwent anterior transfer of the posterior tibial tendon through the interosseous membrane between 1969 and 1979. This included 74 procedures for the following diagnoses: Duchenne muscular dystrophy, clubfoot, cerebrospastic disease (cerebral palsy and head injury). Charcot-Marie-Tooth disease, scapuloperoneal dystrophy, and peroneal palsy. The purpose of this paper is to present the 54 of these transfers that have a minimum 2 year follow-up, were performed with a uniform surgical technique, and had uniform postoperative management. This series is analyzed and compared with a review of the literature in order to set down guidelines for the use of the procedure. The analysis reveals that the patient with Duchenne muscular dystrophy who has decreasing gait function or brace fitting problems is the ideal candidate for the procedure with 26 of 28 satisfactory result. Gait electromyography was critical to the selection of the cerebrospastic patient for the transfer with those patients demonstrating swing-phase function of the posterior tibialis muscle yielding the best results. Finally, posterior tibial tendon transfer is generally not indicated in congenital clubfoot with six unsatisfactory results in 10 procedures, and the procedure should only be done in Charcot-Marie-Tooth disease as part of staged treatment that includes a possible future hindfoot stabilization.

Nonoperative treatment for minimally and nondisplaced lateral humeral condyle fractures in children

The radiographic and clinical records of 95 children with nondisplaced or minimally displaced fractures of the lateral humeral condyle treated on a nonoperative protocol were reviewed. Acute nondisplaced or minimally displaced fractures were defined as < 24 h old on initial evaluation and displaced < 2 mm in three radiographic planes (anteroposterior, lateral, and internal oblique). Closed treatment and close follow-up in a long-arm cast or splint resulted in a union rate of 98% in 3-7 weeks. Two of the fractures displaced required open reduction and internal fixation and then subsequently went on to union without complications.

The effect of wrist deviation on grip and pinch strength.

The effect of wrist deviation on grip and pinch strength was evaluated in 12 normal right-handed adults. Wrist positions of neutral, maximal ulnar (average, 41°), and maximal radial deviation (average, 26°) were held in short–arm casts while grip and key and tip pinch were measured. Wrist position was neutral with respect to flexion and extension. A highly significant effect of wrist deviation on grip strength was found (p < 0.0001). The effect on pinch strength was not statistically significant. Wrist deviation deformities arise in several clinical situations, such as radial clubhand and malunions of the distal radius. A loss of grip strength was found in radial deviation in this study. This would support 1 of the premises for surgical correction of such deviation by centralization or osteotomy.

10-year follow-up of split anterior tibial tendon transfer in cerebral palsied patients with spastic equinovarus deformity.

Summary: Split anterior tibial tendon transfer was performed on 21 patients (27 feet) with cerebral palsy and spastic equinovarus deformity. All patients required orthoses preoperatively. All but two patients are now community ambulators with improved gait and without need for orthoses. There was one recurrence of deformity

Ambulation in severe arthrogryposis.

Functional ambulation occurred in 22 of 36 severely affected arthrogrypotic patients. Functional ambulation in these patients required hip motion to within 30° of full extension and knee motion to within 20° of full extension. Ambulation also required hip extensor strength of good (grade 4), quadriceps strength of fair (grade 3), or crutchable upper extremities and orthotic substitutes. Foot and spine deformities also interfered with ambulatory ability.