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Congenital radio-ulnar synostosis: Surgical treatment
ABSTRACTS
upper limit of normal. The authors wrote the paper to refute the previous literature and establish that surgery can have a successful role in selected cases with adolescent thoracic kyphosis.---Anthony H. Alter The Thoracic Suspension Orthosis. J. C. Drenan, T. S. Renshaw, and P. H. Curtis. Clin Orth 139:33-39, ( M a r c h April), 1979.
Sixty-four patients, managed at the New England Children's Hospital with a thoracic suspension orthosis were studied. The orthosis is made of plastic. It grasps the chest, suspending the patient in the chair so that his buttocks are free of contact. The protocol for teaching patients tolerance to the device as well as details relating to its construction are included in the article. Fifty-nine patients were definitely improved, either in terms of respiratory function, appearance, curvature correction and function. Five patients failed to improve because of lack of cooperation between the patient and/or family, gross obesity, hip joint stiffness interfering with the ability to sit, severe athetoid cerebral palsy and slippage through the orthosis because of progressive cachexia. This equipment should be in the armamentarium of all pediatricians managing the neurologically handicapped children with their progressive spinal deformities.--Anthony H. Alter Management of Severe Spondylolisthesis in Children and Adolescence. D. Boxall, D. S. Bradford, R. B. Winter et al.
J Bone Joint Surg 61A:479~,95, (June), 1979. Forty-three patients with an L-5-S-1 spondylolisthesis greater than 50% were studied. The article reviews the techniques of recording measurements on x-rays as well as the findings at physical examination. Thirty-four patients were treated nonoperatively. The 39 remaining patients had surgery consisting of fusion in 11 patients, laminectomy and fusion in 18 patients plus attempts at reduction with fusion in 10 other patients. Thirty-four of the fusions were of the transverse process type. Myelography was found to be of no value in preoperative assessment except to rule out tumor of the cauda equina. Preoperative assessment revealed significant increase in degree of displacement as the patient was taken from the supine to an upright position. Fusion with or without laminectomy when successful achieved excellent functional results. The authors used Harrington rod instrumentation for spondylolisthesis with a "angle of slipping" of 55 ~ greater. Postoperative management consisted of bilateral leg extension casts, but nonetheless, significant loss in reduction from the initial operative result usually occurred. There is a 25% overall pseudarthrosis rate, felt to be a function of the severe displacement in the cases selected for this paper. The authors concluded there is little place for the nonsurgical treatment of patients with severe displacement. The transverse process fusion has the highest likelihood of success. Postoperative casting seems to make little difference except in the small immature patient.--Anthony H. Alter School Screening for Scoliosis in Athens. P. N. Smyrnis, J,
Valavanis, A. Alexopoulos, et al. J Bone Joint Surg 61B:215-217, (May), 1979.
111
In the screening of school children by the bending test to reveal rib hump or lumbar protrusion, the authors then confirmed the presence of spinal curvature by radiographs, revealing in a random sample of 3494 children, mostly between 11 and 12 yr, an incidence of scoliosis of 9.1% in girls and 3.9% in boys. When curves of 10~ or more were analysed, 4.6% of girls and 1.1% of boys were affected. The incidence of scoliosis in children with fair hair and blue eyes was twice that of those children with dark complexions. No correlation between weight, height and onset of puberty could be found in the development of scoliosis.--M. G. H. Smith Spine Deformity in Neurofibromatosis: A Review of 102 Patients. R. B. Winter, J. H. Moe, D. S. Bradford, el al. J
Bone Joint Surg 61A:677-694, (July), 1979. This is a review article, based on a study of 102 patients with Von Recklinghausen's neurofibromatosis. Eighty patients had curves secondary to dystrophic bone formation associated with neurofibromatosis. The dystrophic curves were refractory to brace correction and required both anterior and posterior fusion to achieve the treatment goals. The results included 16 patients with spinal cord and/or cauda equina compression problems. The nondystrophic curves behaved the same as conventional idiopathic scoliosis. This is a thorough article, based upon a personal e x p e r i e n c e . Anthony H. Alter Fracture-Separation of the Distal Humeral Epiphysis in
Young Children. K. Mizuno, K. Hirohata, and D. Kashiwagi. J Bone Joint Surg 61A:570-573, (June), 1979.
Six epiphyseal fractures of the humerus were reviewed. The arthrographic findings, surgical management and prognosis in this previously rarely described injury were shown. The injury probably exists more frequently than is now known. The problem remains the appropriate technique of diagnosing the injury. The prognosis is good for this injury, assuming adequate reduction.--Anthony H. Alter Lengthening of the Elbow Flexors in Cerebral Palsy. M. A.
Mital. J Bone Joint Surg 61A:515-522, (June), 1979. Six patients with spastic cerebral palsy and associated elbow flexion contractures had a surgical procedure, including Z-lengthening of the biceps brachii and fractional lengthening of the brachialis. The technique is described. All patients had improved cosmetic results, range of motion. Four patients had considerable objective functional improvement. The only complications were keloid formation in the scar. The auth6r concludes, based upon the longest follow-up of 6 yr, that this is a valid procedure in the management of elbow flexion contractures in cerebral palsy.--Anthony H. Alter Congenital Radio-Ulnar Synostosis: Surgical Treatment.
IV. T. Green and M. A. Mital. J Bone Joint Surg 61A:738743, (July), 1979. Thirteen patients with congenital radio-ulnar synostosis were studied 10-25 yr after surgery. The surgical technique
112
was a transverse osteotomy through the conjoined bony mass, placing the hand in the desired position for anticipated function. In bilateral deformities, one hand should be left markedly pronatod for writing and the opposite extremeity placed in twenty to thirty-five degrees of supination. In unilateral synostosis, the ideal position of the radius is 10"-20 ~ of supination. Twelve patients were rated as improved. One patient developed an ischemic contracture of the anterior forearm muscles postoperatively. Two patients required revision of the osteotomy to increase supination. Nine of the patients' subjective evaluation of their results were that they had "normal function." The authors feel that a corrective osteotomy is the preferable approach rather than some form of surgical procedure attempting to restore motion.--Anthony H. Alter A Study of Radio-Ulnar Movements Following Fractures of F o r e a r m in Children. J. S. Daruwalla. Clin Orth 139:114-120, (March-April), 1979.
the
Fifty-three displaced both-bone forearm fractures in children less than 15 yr of age were followed, with greater than 3-yr follow-up. Of the 53 patients, 28 had restricted pronation and supination, although all patients felt subjectively they had an excellent result. Children with greater than 10~ of angulation residuals after the age of 10 yr failed to remodel adequately and to give a normal rotational result. Rotational malalignment in times of reduction was also proved not to undergo remodeling.--Anthony H. Alter Prognosis in Septic Arthritis in the Hip in Children. P. A.
Lunseth and K. G. Heitle. Clin Orth 139:81-85, (MarchApril), 1979. Thirty-eight patients with 39 infected hips were reviewed. Right hips were involved in 24 patients and 24 of the children were males. The age of onset ranged from 14 days to 14 yr, with a mean of 2.9 yr. The duration of symptoms ranged from 1 to 35 days with a mean of 5.1 days. Staphylococcus aureus was the positive culture in 24 cases with staphylococcus pyogenes in 8 and hemophilus influenza in 5. Preferred treatment was surgical, although some patients refused surgery. The data reviewed does not prove that surgical care makes any difference in the ultimate prognosis. Children less than 3 yr of age had a worse prognosis for outcome. The outcome was also affected by the duration of the symptoms prior to intervention of treatment. The non-staphylococcal organisms were less destructive.--Anthony H. Alter Legg-Calve-Perthes" Disease: Results of Discontinuing Treatment in Early Re-Ossification Phase. G. I-1. Thompson
and G. IV. Weston. Clin Orth 139:70--80, (March-April), 1979. There were 169 patients who had complete treatment for Legg-Calve-Perthes' disease studied. The male-female ratio was 5-1. Because many of the patients had had prior treatment before appearing at the Shriner's Hospital in Los Angeles for care, treatment bridged the time span of complete bedrest to the evolution of the containment principles. Results were studied both using the Catterall Classification and the Mose Circle criteria. The Catterall Classification was found feasible because many of the patients were
ABSTRACTS
seen late in the course of their disease. Re-ossification became apparent from 12 to 17 mo post-onset of symptoms with the youngest patients re-ossifying earlier than the older ones. The authors c~ndude, based upon their criteria, that early mobilization of the patient and discontinuance of immobilization and containment devices when re-ossification become apparent, made no difference on the ultimate prognosis of the femoral head. Patients with containment treatment had better results in the Catterall III and IV categories. Surgery should be limited to special situations or hip salvage procedures in older children.--Anthony H. Alter Ligament Injuries in the Knees of Children. G. W. Bradley,
T. C. Shives, and K. M. Samuelson. J Bone Joint Surg 61A:588-591, (June), 1979. Six patients with the rare surgically proved medical collateral ligament injuries of the knee are reported with diagnostic and treatment considerations given.--Anthony H. Alter Sleeve Fractures of the Patella in Children. G. R. Houghton
and C. E. Ackroyd. J Bone Joint Surg 61B:165-168, (May), 1979. In describing three children with injuries of the patella received while vigorously extending the knee in energetic athletics, the authors draw attention to the entity of avulsion of the lower pole of the patella together with an important "sleeve" of cartilage from the articular surface of the patella. Clinically, the diagnosis should be suspected when the knee gives way without direct blow, with severe pain and inability to extend the knee or bear weight. The patella is higher than normal and a palpable gap can be felt in the extensor mechanism at the distal pole. In radiographs the avulsed lower pole may be small and difficult to see. The treatment recommended is accurate anatomical reduction and rigid fixation to maintain the patella articulation.--M. G. H. Smith Congenital Deficiency of the Fibula. C. Achterman and A. Kalamchi. J Bone Joint Surg 61B:133-137, (May), 1979.
In a review of 81 patients (97 limbs) with a diagnosis of congenital deficiency of the fibula, the authors have described a useful simple classification of the condition, based on the degree of deficiency of the fibula. Type I had a hypoplastic, shortened fibula, (Type IA) or a partial absence (Type IB). Type II had a complete absence of fibula. With both types of deficiency other anomalies were present-congenital shortening of the femur, patellar subluxation, tibial bowing, tarsal coalition, and absence of lateral rays of the foot. In a small number, upper limb deficiencies were found. The value of the classification is that Type I deficiencies were mainly dealt with by attention to correct leg length discrepancy, while Type II required amputation and fitting to a prosthesis for satisfactory function.--M. G. H. Smith Caffey's Disease in Cape Town. B. J. Cremin. S A f r Med J
55:377-380, (March), 1979. Six cases of infantile cortical hyperostosis or Caffey's disease are presented with opinions as to its prevalence, incidence and origin.--M. R. Q. Davies
upper limit of normal. The authors wrote the paper to refute the previous literature and establish that surgery can have a successful role in selected cases with adolescent thoracic kyphosis.---Anthony H. Alter The Thoracic Suspension Orthosis. J. C. Drenan, T. S. Renshaw, and P. H. Curtis. Clin Orth 139:33-39, ( M a r c h April), 1979.
Sixty-four patients, managed at the New England Children's Hospital with a thoracic suspension orthosis were studied. The orthosis is made of plastic. It grasps the chest, suspending the patient in the chair so that his buttocks are free of contact. The protocol for teaching patients tolerance to the device as well as details relating to its construction are included in the article. Fifty-nine patients were definitely improved, either in terms of respiratory function, appearance, curvature correction and function. Five patients failed to improve because of lack of cooperation between the patient and/or family, gross obesity, hip joint stiffness interfering with the ability to sit, severe athetoid cerebral palsy and slippage through the orthosis because of progressive cachexia. This equipment should be in the armamentarium of all pediatricians managing the neurologically handicapped children with their progressive spinal deformities.--Anthony H. Alter Management of Severe Spondylolisthesis in Children and Adolescence. D. Boxall, D. S. Bradford, R. B. Winter et al.
J Bone Joint Surg 61A:479~,95, (June), 1979. Forty-three patients with an L-5-S-1 spondylolisthesis greater than 50% were studied. The article reviews the techniques of recording measurements on x-rays as well as the findings at physical examination. Thirty-four patients were treated nonoperatively. The 39 remaining patients had surgery consisting of fusion in 11 patients, laminectomy and fusion in 18 patients plus attempts at reduction with fusion in 10 other patients. Thirty-four of the fusions were of the transverse process type. Myelography was found to be of no value in preoperative assessment except to rule out tumor of the cauda equina. Preoperative assessment revealed significant increase in degree of displacement as the patient was taken from the supine to an upright position. Fusion with or without laminectomy when successful achieved excellent functional results. The authors used Harrington rod instrumentation for spondylolisthesis with a "angle of slipping" of 55 ~ greater. Postoperative management consisted of bilateral leg extension casts, but nonetheless, significant loss in reduction from the initial operative result usually occurred. There is a 25% overall pseudarthrosis rate, felt to be a function of the severe displacement in the cases selected for this paper. The authors concluded there is little place for the nonsurgical treatment of patients with severe displacement. The transverse process fusion has the highest likelihood of success. Postoperative casting seems to make little difference except in the small immature patient.--Anthony H. Alter School Screening for Scoliosis in Athens. P. N. Smyrnis, J,
Valavanis, A. Alexopoulos, et al. J Bone Joint Surg 61B:215-217, (May), 1979.
111
In the screening of school children by the bending test to reveal rib hump or lumbar protrusion, the authors then confirmed the presence of spinal curvature by radiographs, revealing in a random sample of 3494 children, mostly between 11 and 12 yr, an incidence of scoliosis of 9.1% in girls and 3.9% in boys. When curves of 10~ or more were analysed, 4.6% of girls and 1.1% of boys were affected. The incidence of scoliosis in children with fair hair and blue eyes was twice that of those children with dark complexions. No correlation between weight, height and onset of puberty could be found in the development of scoliosis.--M. G. H. Smith Spine Deformity in Neurofibromatosis: A Review of 102 Patients. R. B. Winter, J. H. Moe, D. S. Bradford, el al. J
Bone Joint Surg 61A:677-694, (July), 1979. This is a review article, based on a study of 102 patients with Von Recklinghausen's neurofibromatosis. Eighty patients had curves secondary to dystrophic bone formation associated with neurofibromatosis. The dystrophic curves were refractory to brace correction and required both anterior and posterior fusion to achieve the treatment goals. The results included 16 patients with spinal cord and/or cauda equina compression problems. The nondystrophic curves behaved the same as conventional idiopathic scoliosis. This is a thorough article, based upon a personal e x p e r i e n c e . Anthony H. Alter Fracture-Separation of the Distal Humeral Epiphysis in
Young Children. K. Mizuno, K. Hirohata, and D. Kashiwagi. J Bone Joint Surg 61A:570-573, (June), 1979.
Six epiphyseal fractures of the humerus were reviewed. The arthrographic findings, surgical management and prognosis in this previously rarely described injury were shown. The injury probably exists more frequently than is now known. The problem remains the appropriate technique of diagnosing the injury. The prognosis is good for this injury, assuming adequate reduction.--Anthony H. Alter Lengthening of the Elbow Flexors in Cerebral Palsy. M. A.
Mital. J Bone Joint Surg 61A:515-522, (June), 1979. Six patients with spastic cerebral palsy and associated elbow flexion contractures had a surgical procedure, including Z-lengthening of the biceps brachii and fractional lengthening of the brachialis. The technique is described. All patients had improved cosmetic results, range of motion. Four patients had considerable objective functional improvement. The only complications were keloid formation in the scar. The auth6r concludes, based upon the longest follow-up of 6 yr, that this is a valid procedure in the management of elbow flexion contractures in cerebral palsy.--Anthony H. Alter Congenital Radio-Ulnar Synostosis: Surgical Treatment.
IV. T. Green and M. A. Mital. J Bone Joint Surg 61A:738743, (July), 1979. Thirteen patients with congenital radio-ulnar synostosis were studied 10-25 yr after surgery. The surgical technique
112
was a transverse osteotomy through the conjoined bony mass, placing the hand in the desired position for anticipated function. In bilateral deformities, one hand should be left markedly pronatod for writing and the opposite extremeity placed in twenty to thirty-five degrees of supination. In unilateral synostosis, the ideal position of the radius is 10"-20 ~ of supination. Twelve patients were rated as improved. One patient developed an ischemic contracture of the anterior forearm muscles postoperatively. Two patients required revision of the osteotomy to increase supination. Nine of the patients' subjective evaluation of their results were that they had "normal function." The authors feel that a corrective osteotomy is the preferable approach rather than some form of surgical procedure attempting to restore motion.--Anthony H. Alter A Study of Radio-Ulnar Movements Following Fractures of F o r e a r m in Children. J. S. Daruwalla. Clin Orth 139:114-120, (March-April), 1979.
the
Fifty-three displaced both-bone forearm fractures in children less than 15 yr of age were followed, with greater than 3-yr follow-up. Of the 53 patients, 28 had restricted pronation and supination, although all patients felt subjectively they had an excellent result. Children with greater than 10~ of angulation residuals after the age of 10 yr failed to remodel adequately and to give a normal rotational result. Rotational malalignment in times of reduction was also proved not to undergo remodeling.--Anthony H. Alter Prognosis in Septic Arthritis in the Hip in Children. P. A.
Lunseth and K. G. Heitle. Clin Orth 139:81-85, (MarchApril), 1979. Thirty-eight patients with 39 infected hips were reviewed. Right hips were involved in 24 patients and 24 of the children were males. The age of onset ranged from 14 days to 14 yr, with a mean of 2.9 yr. The duration of symptoms ranged from 1 to 35 days with a mean of 5.1 days. Staphylococcus aureus was the positive culture in 24 cases with staphylococcus pyogenes in 8 and hemophilus influenza in 5. Preferred treatment was surgical, although some patients refused surgery. The data reviewed does not prove that surgical care makes any difference in the ultimate prognosis. Children less than 3 yr of age had a worse prognosis for outcome. The outcome was also affected by the duration of the symptoms prior to intervention of treatment. The non-staphylococcal organisms were less destructive.--Anthony H. Alter Legg-Calve-Perthes" Disease: Results of Discontinuing Treatment in Early Re-Ossification Phase. G. I-1. Thompson
and G. IV. Weston. Clin Orth 139:70--80, (March-April), 1979. There were 169 patients who had complete treatment for Legg-Calve-Perthes' disease studied. The male-female ratio was 5-1. Because many of the patients had had prior treatment before appearing at the Shriner's Hospital in Los Angeles for care, treatment bridged the time span of complete bedrest to the evolution of the containment principles. Results were studied both using the Catterall Classification and the Mose Circle criteria. The Catterall Classification was found feasible because many of the patients were
ABSTRACTS
seen late in the course of their disease. Re-ossification became apparent from 12 to 17 mo post-onset of symptoms with the youngest patients re-ossifying earlier than the older ones. The authors c~ndude, based upon their criteria, that early mobilization of the patient and discontinuance of immobilization and containment devices when re-ossification become apparent, made no difference on the ultimate prognosis of the femoral head. Patients with containment treatment had better results in the Catterall III and IV categories. Surgery should be limited to special situations or hip salvage procedures in older children.--Anthony H. Alter Ligament Injuries in the Knees of Children. G. W. Bradley,
T. C. Shives, and K. M. Samuelson. J Bone Joint Surg 61A:588-591, (June), 1979. Six patients with the rare surgically proved medical collateral ligament injuries of the knee are reported with diagnostic and treatment considerations given.--Anthony H. Alter Sleeve Fractures of the Patella in Children. G. R. Houghton
and C. E. Ackroyd. J Bone Joint Surg 61B:165-168, (May), 1979. In describing three children with injuries of the patella received while vigorously extending the knee in energetic athletics, the authors draw attention to the entity of avulsion of the lower pole of the patella together with an important "sleeve" of cartilage from the articular surface of the patella. Clinically, the diagnosis should be suspected when the knee gives way without direct blow, with severe pain and inability to extend the knee or bear weight. The patella is higher than normal and a palpable gap can be felt in the extensor mechanism at the distal pole. In radiographs the avulsed lower pole may be small and difficult to see. The treatment recommended is accurate anatomical reduction and rigid fixation to maintain the patella articulation.--M. G. H. Smith Congenital Deficiency of the Fibula. C. Achterman and A. Kalamchi. J Bone Joint Surg 61B:133-137, (May), 1979.
In a review of 81 patients (97 limbs) with a diagnosis of congenital deficiency of the fibula, the authors have described a useful simple classification of the condition, based on the degree of deficiency of the fibula. Type I had a hypoplastic, shortened fibula, (Type IA) or a partial absence (Type IB). Type II had a complete absence of fibula. With both types of deficiency other anomalies were present-congenital shortening of the femur, patellar subluxation, tibial bowing, tarsal coalition, and absence of lateral rays of the foot. In a small number, upper limb deficiencies were found. The value of the classification is that Type I deficiencies were mainly dealt with by attention to correct leg length discrepancy, while Type II required amputation and fitting to a prosthesis for satisfactory function.--M. G. H. Smith Caffey's Disease in Cape Town. B. J. Cremin. S A f r Med J
55:377-380, (March), 1979. Six cases of infantile cortical hyperostosis or Caffey's disease are presented with opinions as to its prevalence, incidence and origin.--M. R. Q. Davies