William B. Strecker

Pemberton pelvic osteotomy and varus rotational osteotomy in the treatment of acetabular dysplasia in patients who have static encephalopathy

Forty-four patients (fifty-two hips) who had static encephalopathy and acetabular dysplasia were managed with a Pemberton osteotomy as part of a comprehensive operative approach. Thirty-three patients had quadriplegia and were unable to walk; the remaining eleven patients had diplegia and could walk. The age at the time of the operation ranged from four years and five months to sixteen years and five months, as an open triradiate cartilage is a prerequisite for the Pemberton procedure. Concomitant operative procedures included a varus rotational osteotomy in fifty of the involved hips, a soft-tissue release in thirty-seven hips, and an open reduction in thirteen hips. The mean center-edge angle preoperatively was -11 degrees (range, -80 to 17 degrees), which improved to a mean of 27 degrees (range, 5 to 62 degrees) at the time of the latest follow-up. The mean duration of follow-up was four years (range, two years to eight years and eight months). At the time of writing, none of the hips had redislocated but one hip had subluxated. Eight of the hips had been painful preoperatively, but none of these was painful at the time of the most recent follow-up. One patient who had not had pain in the hip preoperatively had pain at the time of the follow-up evaluation. There were no complications attributable to posterior uncovering of the hip. The age of the patient at the time of the operation had no discernible effect on the result.

Ulnar nerve decompression at the cubital tunnel

A limited surgical decompression of the ulnar nerve within the cubital tunnel by incision of the arcuate ligament was effective in relieving pain and dysesthesia in 22 of 27 patients. No patient had any apparent muscle weakness or atrophy preoperatively. Twenty-five patients had evidence of compression of the ulnar nerve within the cubital tunnel at surgery, as noted by narrowing, hyperemia, or attachment of adhesions to the nerve. Three of four patients who had a subsequent anterior transposition obtained partial relief of symptoms.

Comparison of pronator tenotomy and pronator rerouting in children with spastic cerebral palsy

Forty-one patients with cerebral palsy and pronation contracture of the forearm were treated with pronator teres rerouting compared with 16 patients who were treated with pronator teres tenotomy. The mean age of patients with pronator tenotomy was 4 years 3 months compared with 7 years 3 months for patients with rerouting. Follow-up averaged 94 months for tenotomy and 21 months for rerouting. Average gain in supination was 78 degrees for rerouting and 54 degrees for tenotomy. No patient lost active range of motion during follow-up. Although pronator teres tenotomy increased active supination of the forearm, greater active supination of the forearm was afforded patients treated with pronator teres rerouting.

Management of forearm deformity in multiple hereditary osteochondromatosis

The records of 97 patients with multiple hereditary osteochondromatosis were retrospectively reviewed. Seventy-eight patients had one or more osteochondroma(s) of one or both forearm(s). Fifty-three operations were performed, of which 41 were excisions of symptomatic osteochondromas or dislocated radial heads. All forearm, wrist, and elbow radiographs were reviewed. Four common radiographic parameters were measured: radial articular angle, carpal slip, relative ulnar shortening, and forearm-third metacarpal angle. Thirty-seven of these 78 patients were contacted by telephone questionnaire. The results indicated that skeletally mature patients do well on a functional basis and are comfortable with their appearance, despite deformity. Surgery can improve aesthetic appearance and provide pain relief when done before or after skeletal maturity. Because of these results, we are less aggressive in the early treatment of forearm deformities.

A Surgical Technique of Radioulnar Osteoclasis to Correct Severe Forearm Rotation Deformities

Summary Twenty-six forearms in 23 patients with marked pronation or supination deformities were treated with osteoclasis. Etiologies included 12 radioulnar synos-toses, five brachial plexus injuries, three hemiplegias, two hemimelias, and four other types of deformities. Drill-assisted osteotomy of both the radius and ulna was followed 10 days later by manipulation to the desired functional position. Dominant extremities were placed in 20° pronation, and nondominant extremities in 20° supination. Range of motion was not significantly changed, but the arc of motion occurred in a more functional hand position. Average correction for 15 pronation deformities was 81° and 69° for 11 supination deformities. Two nonunions healed after bone grafting and there were no instances of neuromuscular compromise. Functional improvement was obtained in 25 of 26 forearms.

Surgical treatment of displaced olecranon fractures in children.

Thirty-five children who had fractures of the olecranon were reviewed. Age at the time of injury ranged from 0 years 2 months to 15 years 4 months. Fractures were retrospectively classified as type I or II according to the amount of displacement apparent on the initial radiographs. Type I fractures were those with < 3 mm of displacement, and type II were those with displacement of > or = 3 mm. Type I fractures (n = 23) were treated with closed methods, and splint or cast immobilization was maintained for an average of 3 weeks. All 23 type I fractures had satisfactory results on follow-up. Type II fractures (n = 12) were treated with open reduction and internal fixation. Greater intraarticular displacement was often seen intraoperatively than had been appreciated radiographically. Ten of 12 patients with type II fractures were available for follow-up; all had satisfactory results. Restoration of the articular surface in children with olecranon fractures optimizes joint function and growth potential. The amount of fracture may be more than is apparent on plain radiographs.

Anterior elbow release of spastic elbow flexion deformity in children with cerebral palsy.

This study evaluated anterior elbow release for spastic elbow flexion deformity in children with cerebral palsy. Forty-two consecutive surgical procedures are reported in 40 children with a minimum of 1 year of follow-up. The procedure included incision of the lacertus fibrosus, fractional lengthening of the brachialis aponeurosis, and denuding the peritendinous adventitia from the biceps tendon to remove afferent nerve fibers and receptors. Preoperative and postoperative measurements of the flexion posture angle, active extension, and active flexion were obtained, as well as completion of a written questionnaire by the parents. Flexion posture angle improved from 104° before surgery to 55° after surgery, a reduction of 49°; active extension improved from 43° to 27°. There was no significant change in elbow flexion. Before surgery, the average percentage use of the arm was 12%, which improved significantly to 44% after surgery. The authors conclude that anterior elbow release can significantly improve the flexion posture angle and active extension of the elbow, as well as both the functional use and aesthetic appearance of the involved upper limb.

Use of the Herbert bone screw for scaphoid nonunions

The Herbert bone screw was used to treat 22 selected patients with established scaphoid nonunions. The indications for its use included evidence of avascular necrosis, proximal third fracture fragment, previous bone graft, fracture angulation or displacement, and a bipartite scaphoid. Treatment resulted in radiographic and clinical evidence of healing in 16 patients; 4 patients were symptom-free, but had incomplete healing as evidenced by radiograph; and 2 patients had persistent symptoms with radiographic evidence of nonunion.

Polyarticular pigmented villonodular synovitis in a child

Pigmented villonodular synovitis is rare in the younger child. Polyarticular involvement in this condition, regardless of patient age, is distinctly uncommon. The authors describe a case of pigmented villonodular synovitis involving multiple joints in a young boy who also had congenital anomalies of the genitourinary tract. Although rare, pigmented villonodular synovitis should be considered in the differential diagnosis of multiple joint swellings in children with congenital anomalies.

Closed reduction of developmental dislocation of the hip in children older than 18 months

Thirty-eight hips in 32 patients > or = 18 months of age had closed reduction attempted for developmental dislocation of the hip. Twenty-six hips in 24 patients had an initially successful closed reduction. During cast treatment three of 26 hips had progressive subluxation or dislocation requiring open reduction with or without concomitant osteotomies. The remaining 23 hips, with an average follow-up of 8 + 8 years, are thought to have had a successful closed reduction. Eleven of those hips have required no further surgical procedures and had an average acetabular index of 18 degrees at last follow-up. Twelve of the 23 hips that had successful closed reduction required a femoral or pelvic osteotomy for failure to remodel. Younger age (< 22 months) at the time of reduction and lower grade (I and II) dislocation were favorable prognostic indicators of the likelihood of successful closed reduction.