Introduction: The incidence of scoliosis in patients with myelomeningocele has been reported to be as high as 80 to 90% in some studies. However these studies included patients with both congenital and developmental curves. The purpose of this study is to identify clinical and radiological factors, which may predict the development of scoliosis in patients with myelomeningocele. Methods: A retrospective review of the charts and radiographs of all patients with myelomeningocele seen in our clinic between 1990 and 1995 was performed. Selection criteria for the study included: a diagnosis of myelo-meningocele or lipomeningocele, age greater than 10 years, serial documentation of motor power testing, and a radiographic documentation of spinal deformity primarily in the coronal plane. Statistical analysis was performed to obtain predictive values, specificity and sensitivity for each of the following factors: clinical motor level, functional status, motor asymmetry and hip instability. Radiographs were examined to obtain the last intact laminar arch in these patients. The relationship between the last intact laminar arch and scoliosis was evaluated. Results: 141 patients satisfied the inclusion criteria. Seventy-four patients (53%) developed scoliosis. The mean follow-up was 9.4 years (range 3–30 years). The average age of the patient population was 19 (range 10–42 years). Forty-three patients developed scoliosis before nine years of age. New curves continued to develop until 15 years of age. Curves less than 20° often resolved. Clinical motor level, functional status, motor asymmetry and the last intact laminar arch were all found to be predictive for scoliosis in these patients. The presence of spasticity and hip instability had no definite influence on the development of scoliosis. Conclusion: The term scoliosis should be reserved for curves greater than 20° in patients with myelomeningocele. New curves may continue to develop until 15 years of age. The last laminar arch is a useful early indicator of scoliosis in these patients

Introduction: Since 1989 vertebral resection with modified Luque fixation has been the procedure of choice for correction of myelomeningocele kyphotic deformity at this institution. The purpose of this study was to evaluate long-term results with this technique. Treatment or congenital kyphosis in myelomeningocele is a difficult problem. Current thinking supports kyphectomy and post-operative internal fixation. The majority of authors agree that kyphotic deformity in myelomeningocele should be treated with vertebral resection. There is less uniform consensus as to postoperative fixation. Literature reports appear to support fixation with modified segmental instrumentation. Methods and Results: 16 patients, followed for an average of 57.2 months (36–94 months), underwent vertebral resection from the proximal aspect of the apical vertebra cephalad into the compensatory lordotic curve. Fixation was segmental instrumentation wired to the thoracic spine and anterior to the sacrum. The average blood loss was 1121 cc (450–2580 cc.). Pre-operative kyphotic deformity averaged 111° (75–157°), postoperative 15° (−18° –36°) and latest follow-up of 20° (−17° –83°), with loss of correction of 6° (0–27°). Post-operative immobilisation was with a TLSO for 18 months. Complications occurred in eight of the 16 patients: (1) transient headache (2), superficial wound breakdown (2), supracondylar femur fractures (2), and one late infection secondary to skin breakdown necessitating early rod removal and some loss of correction. Conclusions: Kyphectomy is an excellent method of correcting rigid kyphotic deformity in the myelodys-plastic patient. Segmental spinal instrumentation provides three distinct advantages: rigidity of the construct, greater correction of the deformity and low-profile instrumentation

Introduction and Objectives: This is a retrospective clinical and radiographic study of 19 patients affected by paralytic scoliosis secondary to myelomeningocele who were treated surgically with double anterior fusion (without anterior instrumentation) and instrumented posterior fusion from T2 to the sacrum. Materials and Methods: The study involved 19 patients with scoliosis secondary to myelomeningocele treated surgically by instrumented posterior fusion (3 cases) or double anterior fusion (non-instrumented) with instrumented posterior fusion from T2 to the sacrum (10 cases). Instrumentation consisted of two rods shaped in physiologic kyphosis and lordosis, sublaminar wiring, and anchoring to the pelvis using the classic Galveston technique (7 patients); two rods fixed to the spine by means of sublaminar wires and pedicle screws on the convexity of the curve in the lumbar region and an iliac screw in the pelvis (11 cases); and in one case, anchoring to the pelvis was achieved using an iliosacral screw. Results: Age of the patients ranged from 9 to 16 years, with a mean of 12 years. There were 11 females and 8 males. Maximum time of patient review was 9 years, and minimum time was 2 years. The level of spinal cord involvement was thoracic in 1 case, upper lumber (L1–L2) in 6 cases, mid-lumbar (L3) in 7 cases, and lower lumber (L3–L4) in 5 cases. Curve patterns were thoracolumbar (apex at T12–L1) in 14 cases and lumbar in 5 cases. Pre-operative curve angles ranged from 60° to 133° with a mean of 93°. Postoperative curve ranged from 15° to 60° with a mean of 42°. There were 6 patients with thoracolumbar kyphosis ranging from 24° to 92° (mean 49°) and 15 patients with pelvic obliquity ranging from 14° to 42° (mean 28°). Decompensation of the trunk with respect to the pelvis ranged from 26 to 0 cm, and postoperatively ranged from 13 to 0 cm (mean 5.5 cm). Of the 19 patients, 9 (50%) experienced complications. One patient presented with non-union and a subsequent delayed infection requiring four operations and removal of material. There were 3 patients that experienced postoperative infections requiring surgical drainage, with 2 cases of leakage of CSF, which resolved with postural therapy. In 5 cases, there was necrosis of the vertex of the triradiate incision, and in one case there was failure of the iliac screw in the pelvis with no clinical consequences. Discussion and Conclusions: The use of a triradiate incision avoiding a direct approach to the sacral dura, a double anterior and posterior approach in cases of rigid curve (radiographic examination in traction) and saggital deformities (thoracolumbar kyphosis), and the use of pedicle screws in the distal vertebrae and in the iliac wing allow the correction of frontal and sagital deformities and pelvic obliquity in patients with myelomeningocele

Background:. Severe kyphosis in myelomeningocoele patients results in seating problems, early satiety and ultimately pressure sores over the prominence. Kyphectomy and sagittal correction can improve these morbidities. Aim:. To evaluate the outcome of kyphectomy surgery in meningomyelocoele children. Methods:. A retrospective review was performed of a single surgeon series of paediatric myelomeningocele patients who underwent kyphectomy surgery. All the patients had posterior fusion, employing pedicle screws and sub laminar wiring. All the posterior fusions extended to the pelvis either to include S1 or the ilium. Prior to surgery, three children had open wounds over the apex of the deformity. Despite prone nursing, these failed to heal. These were closed primarily intra-operatively without the requirement of flaps. Results:. Seven children (four males, three females) were identified with an average age of 9.5 (8–13) years. The kyphosis was corrected from a mean range of 110° (88°–180°) to post-operative range of 5°–45°. The operative time averaged 240 min (165–284 min) with an estimated blood loss average of 957 ml (500–2550 ml). All the patients recovered well and no short-term complications were experienced except one transient CSF leak intra operatively. Two patients presented with sub-acute delayed infection requiring removal of instrumentation once the spine had fused. There was one case of instrumentation failure. All patients had improved wheel chair seating. Conclusion:. Kyphectomy in myelomeningocele is an infrequently required procedure which is effective in sagittal correction and improved seating with an acceptable complication rate

Purpose: To give the review of the foot deformities in the patients with myelomeningocele (MMC), their relationship to the level of the neurological lesion and therapeutic possibilities. Material & Methods: Since 1998 till 2004 there were 20 patients with myelomeningocele treated in our clinic, in 19 patients was noted the foot deformity (total 34 feet). The deformity was unilateral in 4 patients, asymmetric in 2 patients (equinovarus + calcaneovalgus or planovalgus). The most frequent was equinovarus deformity (16 feet, 47%), next planovalgus deformity (9 feet, 26,5%), calcaneovalgus (7 feet, 20,6%) and equinovalgus (2 feet, 5,9%). In 28 feet the surgery was done. For the correction of the various deformities of the feet were used soft tissue releases or tendons transfer, in the older patient or after failed soft tissue release the bony operation was done (tarsal osteotomy, talo-calcaneal stabilisation, artrodesis). Results: The aim of every type of surgery was to achieve the acceptable foot shape, with plantigrade step and possibility of weigh bearing, with minimal risk of the pressure necrosis. In the most patients the purpose was achieved, although some of them passed several surgeries. In 18 deformities only one surgery obtained the correction of the deformity, the but for the 10 feet subsequent surgery was required because of the residual or relapsing deformity. In 3 patients was noted the pressure necrosis, in 1 patient appeared the fracture of the distal tibia (epiphyseolysis) after the removal the postoperative plaster. Conclusion: The orthopaedic care about the patients with MMC is only a part of the interdisciplinary approach of several specialists. The procedures for the correction of the neurogenic deformities of the feet, belong to the delicate surgery and is necessary very careful indication in relation with the type of deformity, which is dependent on the high of the lesion, and with the expectancy of walking. In the patients with good prognosis of walking is necessary to choose the procedure which guarantee weight-bearing and plantigrade step without the risk of ischemic skin defects

Due to the increasing rate of relapses and the morbidity degree that this implies, we report our experience and results in the treatment of clubfoot in patients with myelomeningocele. Between February 1996 and February 2001 12 patients with myelomeningocele (16 feet with clubfoot deformity and 4 bilateral cases) underwent surgical treatment. 5 were boys and 7 were girls. 3 relapsed cases were referred to our institution, 1 of them had a bilateral involvement. The average age at time of surgery was 27 months (range 7 months–5.3 years). Levels of functional involvement were recorded according to Caneo (Argentina Chapter of Neuroorthopaedics) classification: Caneo 0: 2 patients, Caneo 1: 4 patients, Caneo 2: 8 patients, Caneo 3: 1 patient. Relapses occurred in 3 cases; 2 with tendon lengthening technique and 1 tibialis posterior transfer to lateral peroneus brevis, split tibialis anterior tendon transfer. The complications were postoperative infection in 3 cases with wound dehiscence, tibia fracture after cast removal in 1 case and residual tibia intrarotation in 1 case. AFO were used in patients older than 2 years old with Caneo type 2 and 3 and RGO in patients with Caneo type 0 and 1. The final results after solving all the complications were: 6 plantigrade feet, 1 intrarotated plantigrade foot and 1 relapsed inverse foot undergoing release of filum terminale with tethered spinal cord. In conclusion, we consider the most effective technique the one that presents the lower rate of relapses and with efficient functional outcomes. We agree with Luciano Dias opinion that regional resection of all the tendinous elements is the best option to fulfill our goals. We strongly advice a tendon lengthening or transfer in patients belonging to Caneo classification type 3

Treatment of congenital kyphosis with severe angular dysplastic spine in children with myelomeningocele (MMC) is one of the most difficult spinal procedures. Most of the surgeons support kyphectomy with long segmental spinal instrumentation and postoperative immobilization by thoracolumbosacral orthosis. Several spinal deformities are seen frequently in patients who have MMC. The deformity may be congenital or paralytic. Congenital lumbar kyphosis is less common, but most difficult in patients with MMC, occurring in 10–20% of patients. Most curves are congenital and rigid, often more than 80° at birth, and rapidly progresses. With progression of kyphotic deformity, patients experience recurrent skin breakdown over the apex of the kyphos; impaired sitting balance; the necessity of using their hands for support; collapsing spine and decreasing of lumbar height reduce the capacity of the abdominal cavity and resulting in reduced respiratory capacity and malnutrition. The poor posture and short abdomen make it difficult to manage the patients’ urological needs. A severe deformity raises difficulties in social and psychological development. Non-operative treatment with spinal orthoses may provide only temporary correction of a kyphotic deformity, but does not prevent progression and skin breakdown. The goal of surgical treatment is correction of spinal deformity by long segmental instrumentation and achievement of a solid spine fusion in order to allow a balanced sitting position and to prevent complications. From 1983 to 2001, 6 patients with thoracic level myelomeningocele and severe kyphotic deformity were referred for surgical correction. There were 5 males and 1 female patients with average age at the time of surgery of 8.3 years (range 4.3–13 years). All patients suffered from severe kyphosis, range 90° to 130°, average – 108°. All of them underwent posterior ligation of spinal cord during resection of lordotic segment of the kyphos, and segmental spinal fixation of the deformity from the thoracic spine to the sacrum. In all cases following the resection of the vertebrae it was possible to correct the deformity. All patients were available for follow-up with range of 6–216 months, average 85 months. All of them were satisfied with the surgical outcome and presented in their final clinical examination with balanced and comfortable sitting, without soft tissue complications. In all cases a significant correction of the deformity was achieved (15°–30°) and enabled comfortable and stable sitting. Two patients suffered post-operative complications, one from surgical wound infection which required surgical debridement followed by soft tissue covering, and the other suffered from distal migration of the rod which was shortened later on. Discussion: Kyphotic deformity in a patient who has MMC is a challenge for the orthopaedic surgeon and requires major surgical intervention. Resection of the kyphos with posterior instrumentation and fusion may solve patient’s functional problems

We treated 31 feet in 17 children with myelomeningocele by extra-articular subtalar arthrodesis. Two patients were lost to follow-up. In the rest, we assessed the correction of valgus deformity and the growth of the tarsal bones. At operation the mean age of the eight girls and nine boys was 6.3 years (3 to 9). At a mean follow-up period of 5.5 years (3 to 9) patients were evaluated clinically and radiologically. We assessed calcaneal growth by calculating the ratio of calcaneal and naviculo-metatarsal longitudinal length on the preoperative and follow-up lateral radiographs. Results of valgus correction were good in 19 feet. In eight they were unsatisfactory owing to progressive valgus of the ankle. Orthotic fitting was difficult and pressure sores over the medial malleolus often developed. Four of the patients underwent further correction by distal tibial osteotomy. The growth ratio was increased in 15 feet, remained the same in seven and decreased in five. Extra-articular subtalar arthrodesis produced satisfactory partial correction of a complex valgus deformity and stability of the hindfoot, and did not have a detrimental effect on the growth of the calcaneus

We conducted a long-term follow-up study to determine the functional status and level of social integration of 67 children with myelomeningocele. All of them attended a Spinal Defect Clinic for at least four years between 1968 and 1979, and all attended a Rehabilitation School for at least four years, either as day scholars or as boarders. An analysis of their functional walking abilities was presented at the congress in 1979. Hospital and school records were obtained, and patients were asked to complete a questionnaire about their marital status, children, employment and educational status. Further questions asked about change in ambulatory status, sphincter status, urinary tract problems, numbers and types of operations performed after 1979, and whether they were satisfied with the results. We traced 55 of the 67. There had been 12 deaths, most as result of urosepsis. Many patients had moved from the area. Many were in homes or living secluded lives and unwilling to get involved. Many patients had undergone more surgery, particularly amputation of the feet or legs. After leaving the Rehabilitation School, many patients became wheelchair-bound: these were extremely unhappy and felt they had been misled by the promise that they would continue to walk. All were over-weight. The 10 patients who had spinal surgery were delighted with the result. Many were happy with the medical management and education they had received in childhood, and felt privileged to have their support systems. Many were gainfully employed and married with children. The long-term follow-up study revealed that in adulthood the order of priorities of these patients remained the same as in childhood and adolescence. Most important was communication, then activities of daily living. Transportation and ambulation were secondary issues

Aims

The aim of this study is to define a core outcome set (COS) to allow consistency in outcome reporting amongst studies investigating the management of orthopaedic treatment in children with spinal dysraphism (SD).

Introduction: Foetal surgical repair of myelomeningo-cele protects the spinal cord and prevents the development of Chiari malformation and hydrocephalus. The procedure needs manipulation of the fragile foetal tissues and tension free closure of the skin.

With translational purposes, since January 2004 we have developed a novel foetal procedure in a sheep model that avoids foetal tissue manipulation. The technique consists in a gentle coverage of the defect using an inert patch sheet secured by a surgical sealant. results in the animal model showed adequate protection of the spinal cord and prevention of the Chiari malformation. Later on, this technique has been used in two human foetuses.

Case 1: Female foetus 24 weeks old. Lumbar myelo-meningocele, spontaneous mobility of the legs, mild ventricular dilatation, previous c-section and posterior placenta.

Foetal repair was done in August 2008 by means of closure of the dural sac and coverage with a patch of collagen-elastin matrix) secured with surgical sealant.

Birth delivery happened at 31 weeks due to uterine rupture in the scar from a previous c-section. At birth, the newborn weighted 1.5Kg, and showed a complete closure of the defect without leakage of cerebrospinal fluid, and normal legs mobility. Cranial MRI showed small cerebelar herniation and small ventricular dilatation. One year after birth the baby is able to walk, but the ventricular dilatation has progressed and a shunt was placed on at 11 months of life.

Case 2: Male foetus 23 weeks old. Lumbosacral defect, spontaneous mobility of the legs, mild ventricular dilatation, cerebelar herniation, previous c-section and anterior placenta.

Foetal repair was made in January 2009 by means of closure of the dural sac and coverage with a patch secured with surgical sealant.

Birth delivery was done at 30 weeks due to oligoamnios. At birth the newborn weighted 1Kg, and showed closure of the defect without leakage of cerebrospinal fluid, and normal legs mobility. Cranial MRI showed correction of the Chiari malformation and no ventricular dilatation. Eight months after birth the baby is fine and stable.

Conclusion: Surgical foetal coverage of myelomenin-gocele using inert patch and surgical sealant is a fast and gentle procedure for the foetus that avoids tissue manipulation, enhances closure of the defect and prevents Chiari malformation and hydrocephalus.

Introduction: In children with MMC characteristic kinematic gait patterns and center of mass motion have been identified for different lumbo-sacral levels, which may vary in specific muscle paresis definitions and ambulatory outcome. The goal was to investigate compensatory movements employed in MMC in groups with successive paresis in the following major muscle groups: plantarflexors, dorsiflexors, hip abductors and hip extensors.

Patients and Methods: 28 children with MMC (m=10.3 y), walking independently participated in a gait study. A classification based on paresis on the primary muscle groups was established using standard Manual Muscle Test (MMT). Five groups of MMC were established based on successive paresis (0-2 MMT) of the plantarflexors,dor-siflexors, hip abductors, and hip extensors. Subjects were tested in their habitual orthoses, if any. All children underwent full-body three-dimensional gait analysis (VICON, Oxford). Five kinematic cycles from each side were analyzed and group averages were calculated.

Results: The most striking compensatory movements were observed in the frontal and transverse planes in the trunk, pelvis, and hips. Trunk sway increased sequentially from Groups 1 to 5, with the largest interval occurring at the onset of hip abductor paresis (Group 4). Trunk and pelvic rotation were observed to completely alter at the onset of hip abductor paresis (Group 4), where an internal position occurs during stance and external during swing. ‘Pelvic hike,’ or the lifting of the pelvis during swing, was observed in as early as Group 2 with plantarflexor paresis, becoming more pronounced in the latter groups. Large hip abduction was observed during stance at the onset of hip abductor paresis (Group 4). The onset of dorsiflexor paresis result in few kinematic changes since all subjects in Groups 2 and 3 wore orthoses. Sagittal plane differences were observed at the onset of hip extensor paresis (Group 5), where the trunk and pelvis were more posteriorly tipped and hips less flexed.

Discussion The classification method aids in understanding the specific compensatory mechanisms employed when the muscle functions are successively lost. Plantarflexor paresis is evident in all three planes in even the trunk. Abductor weakness results in large frontal and transverse plane changes. Hip extensor weakness is mostly evident in the sagittal plane. By understand-ingthe characteristic movements employed, an improved basis for evaluation and treatment can be established.

Previous studies have documented a variation in the occurrence of musculo-skeletal conditions affecting the hip and foot in the New Zealand Maori and Pacific Island races compared with the European race in New Zealand. Similar data regarding scoliosis are lacking. A manual and computerised review of outpatient records of Starship Hospital (1989–2000) and Middlemore Hospital (1997–2000) revealed 363 patients less than 20 years of age with a diagnosis of scoliosis. Major aetiological diagnoses included adolescent idiopathic (63), syringomyelia (12), myelomeningocele (16), cerebral palsy (55) and congenital (55). Significant racial variations were noted in the idiopathic, syringomyelia and neuro-muscular groups compared with New Zealand census predictions. Idiopathic scoliosis was uncommon in Maori (9%) and rare in Pacific Islanders (1%). Conversely, these groups accounted for 66% of all scolioses and over 50% of Maori and Pacific Islanders were found to have a syrinx. MRI is indicated in Maori and Pacific Islanders with apparent adolescent idiopathic scoliosis. Maori accounted for 31% of patients with myelomeningocele and scoliosis. 40% of patients with cerebral palsy and scoliosis were Maori, reflecting the known inferior status of perinatal and other health parameters in this group of people

The development of spinal deformity in children with underlying neurodisability can affect their ability to function and impact on their quality of life, as well as compromise provision of nursing care. Patients with neuromuscular spinal deformity are among the most challenging due to the number and complexity of medical comorbidities that increase the risk for severe intraoperative or postoperative complications. A multidisciplinary approach is mandatory at every stage to ensure that all nonoperative measures have been applied, and that the treatment goals have been clearly defined and agreed with the family. This will involve input from multiple specialities, including allied healthcare professionals, such as physiotherapists and wheelchair services. Surgery should be considered when there is significant impact on the patients’ quality of life, which is usually due to poor sitting balance, back or costo-pelvic pain, respiratory complications, or problems with self-care and feeding. Meticulous preoperative assessment is required, along with careful consideration of the nature of the deformity and the problems that it is causing. Surgery can achieve good curve correction and results in high levels of satisfaction from the patients and their caregivers. Modern modular posterior instrumentation systems allow an effective deformity correction. However, the risks of surgery remain high, and involvement of the family at all stages of decision-making is required in order to balance the risks and anticipated gains of the procedure, and to select those patients who can mostly benefit from spinal correction.

Grice-Green subtalar arthrodesis was initially reported to correct valgus hindfoot deformities in patients with poliomyelitis. Nowadays, the indications of the Grice-Green arthrodesis have been significally broadened. The aim of this study is to analyse the indications of treatment and evaluate the results of the Grice-Green arthrodesis in children. During the period 1986–2006, 17 children with valgus hindfoot deformities were treated in our department. In 12 of them the procedure was performed in both feet and in the rest (5 patients) unilaterally. The mean age at operation was 8.8 years. The most common group of patients suffered from cerebral palsy (10 patients), followed by the patients suffering from myelomeningocele (4 patients), 2 patients suffered from overcorrection following treatment of congenital equinovarus and one patient from Charcot Marie Tooth disease. In neine patients the operation was combined with Achilles tendon lengthening, capsulotomies, tendon transfers, tendonotomies, and Evans arthrodesis. In all operations bone graft from the tibia or the fibula was used. Postoperatively a balow knee non weightbearing cast was applied for 8 weeks followed by a weightbearing cast for 4 weeks. The results were avaluated according to Alman and Zimbies criteria. The mean follow up of the patients was 4.2 years. The results in 24 feet were considered excellent and in 5 cases satisfactory. In all cases subtalar arthrodesis was achieved. Grice-Green arthrodesis is a very useful operative technique for the correction of severe valgus hindfoot deformities in children. The results of the technique are usually good and the operation does not influence the normal growth of the foot. An accurate preoperative planning and a good surgical technique is neccesary for good results

Open fetal surgery for reparation in myelomeningocele reverses Chiari II malformation and protects exposed neural elements from secondary lesion, but the technique is associated with a high rate of complications. The aim of our study was to assess whether a simple and fast technique of coverage produces the same results as a complete and longer technique of reparation in terms of neural protection. Twelve sheep’s foetuses underwent lumbar three-level laminectomy and opening of the dura-mater on the 75th day of the gestation. Four of them were not-repaired (NR group). Eight of them underwent coverage with inert material sheet and synthetic surgical sealant on the 95th day (R group). At birth, clinical and histological examination and comparison between groups was performed. None NR animal were able to stand or to walk nor had sphincter continence; all of them showed a wide defect of closure in the lumbar area, continuous leakage of cerebrospinal fluid (CSF), and histological neural damage; the mean vermis herniation was 75%. All R animals were able to stand and to walk and all of them showed sphincter continence; none of them showed leakage of CSF and showed coverage of the 93% of the defect; all of them showed regeneration of dura-mater, muscle and skin; the mean vermis herniation was 10%. A simplified technique of coverage produces the same clinical results than a more complex reconstruction in a model of surgical MMC in sheep and the histological study reveals the regeneration of several layers of soft tissues

Neurological problems such as cerebral palsy, myelomeningocele and others may lead to unstable hips in children and juvenile patients. Major problems may arise due to the inability to treat the underlying condition. Patients may suffer from spasticity, reduced muscular tone, bone loss or bony deformity. Despite these problems several tactics are used to gain long-term reduction of unstable hips. Femoral osteotomies are done alone or in combination with pelvic osteotomies, and/or muscular procedures. The indication of the femoral osteotomy alone is the unstable hip with a normal pelvic anatomy shown in the three-dimensional computed tomography (CT). Long-term follow up (11 to 18 years) of patients with intertrochanteric femoral osteotomy alone resulted in hip centration if patients were younger than four years of age at the time of surgery. In older patients hip centration always improved but femoral osteotomies alone did not result in sufficient coverage of subluxated or dislocated hips. Therefore in these patients with pelvic deformity we perform an intertrochanteric varusderotation and shortening osteotomy to correct the femur deformity in combination with a Pemberton type peri-acetabular pelvic osteotomy, an open reduction of the hip joint and a capsuloraphy

Talectomy was performed on 31 rigid clubfeet in 13 boys and 10 girls. Sixteen patients had myelomeningocele and seven arthrogryposis. The procedure was undertaken as a salvage operation on 22 feet. Seven patients had an additional cuboidectomy. The mean age of the patients was 3.7 years (2 to 9). The patients were followed up for a mean of 4.5 years. Assessment included foot position, appearance and mobility, orthotic or shoe-wear fitting and walking capacity. Calcaneal position at the ankle was assessed radiologically. The results in 18 feet were good and in seven were satisfactory. There were six failures. Primary talectomy produced better results in children above the age of two years than ssecondary procedure in the older children. One of the patients developed a severe vascular complication, followed by sepsis, and required amputation of the foot. The other failures were due to recurrence of equines deformity. Talectomy performed for severe rigid clubfoot achieved satisfactory correction in most of our patients. Excision of the talus as a salvage procedure carries a risk of incomplete correction and vascular complication

Purpose: To describe the Halifax anterior-posterior kyphectomy, and report on a series consecutive patients. Method: Twenty-two patients received a Halifax kyphectomy over a 23 year period. Patient charts were examined, and radiographs measured pre- immediately post- and at final follow up. Cobb’s method was used to determine kyphosis angle. The procedure itself involves an apical kyphectomy, and cord transection if necessary, followed by the insertion of two rods distally and anteriorly in the vertebral bodies. This is followed by sublaminar wires superiorly and reduction of the kyphosis. Data was analysed to attempt to find a correlation between age, deformity, OR time, length of stay and maintainence of correction. Results: Mean age was 7.59 years (2–17); mean pre-op kyphosis was 123.19 degrees (79–163); post-op 40.43 degrees (13–92); mean correction of 82.29 (39–153). Mean follow-up was 6.38 years (0–14); mean kyphosis at follow-up was 60.24 degrees (14–126), mean final correction of 63.43 degrees (−37–162); mean loss of correction 19.33 degrees (−9–76). The average OR time was 247.86 minutes (180–345); EBL 765cc (140–2100) and length of stay 13.68 days (1–57). Eight patients required hardware removal, and two of these required revision surgery. The other six patients maintained correction without hardware, and did not require re-operation. One patient had a rod fracture, but did not require revision or removal. Twelve patients had no complications. There was one intra-operative mortality. Conclusion: The Halifax kyphectomy is a safe, effective treatment for kyphosis in myelomeningocele patients. Outcomes in this series are comparable to the available literature

Juvenile hip instability is associated with many conditions. Most of them belong to the group of neuromuscular diseases. Generally following categories can be enumerated: 1. Cerebral palsy, 2. Myelomeningocele, 3. Spinal cord injury, 4. Paraplegia following spine surgery, 5. Poliomyelitis, 6. Inflammatory hip disease, 7. Idiopathic instability, 8. Recurrent post-traumatic hip instability. In the groups 1–5 a chronic muscle imbalance is the reason of the displacement of the femoral head. Inflammatory joint disease produces displacement through cartilage and bone destruction and increased intra-articular pressure. Very rare idiopathic instability is usually associated with generalised hypermobility. For the early diagnosis a careful clinical examination is necessary involving range of motion, testing of the hip stability by the Palmén’s test in the same way like in new-borns. Routine x-ray screening at least once per year is mandatory. For the groups 1–5 a muscle imbalance has to be corrected first. Elimination of muscles contractures or muscles transfers respectively, showed a high efficiency if these surgical corrections were performed early. Femoral osteotomy alone does not provide reliable results. Any form of pelvic osteotomy is necessary to correct acetabular insufficiency. For the inflammatory hip disease early active surgical treatment is best prevention of displacement. Idiopathic hip instability has to be differentiated from common snapping hip. No treatment is necesary. Recurrent hip dislocation can be cured by a posterior capsulorrhaphy