Patients with spastic diplegia who walk with a crouched posture often suffer from anterior knee pain, thought to be due to cephalad displacement of the patella. Ambulation with flexed knees elongates the patellar tendon, which leads to development of patella alta. Our study of 57 patients with spastic diplegia aimed to determine the severity of patella alta and to investigate its correlation with spasticity and muscle imbalance at the level of the knee. The ages of the 31 male and 26 female patients ranged from 3 months to 16 years. They were divided into two groups, one with spasticity of the hamstrings and the other with combined spasticity of the quadriceps and hamstrings. Clinical evaluation documented anterior knee pain, walking capacity, fixed deformities, hamstrings and rectus femoris shortening, and patellar mobility. Lateral radiographs were taken to measure the length of the patella and the patellar tendon. We used the method described by Insall and Salvati to calculate the patellar ratio. The clinical findings were examined for correlations with the severity of patella alta. We found that the group of patients with quadriceps and hamstring spasticity had a higher rate of patellar displacement but less frequent anterior knee pain than the group of patients with hamstring spasticity alone.
Jimmy Craig had many talents and virtues. A keen sportsman, he played rugby for his school and university and in his younger days was an amateur boxer of note. Directly from medical school he joined the Medical Corps of the South African Forces fighting in the Western desert, and then went up the boot of Italy. On his return to Johannesburg, his home town, he developed expertise in cerebral palsy treatment and surgery. From about 1970 until the year before his death in 1992, he regularly visited Ikhwezi Lokusa School for the Orthopaedically Handicapped, just outside Umtata, once or twice a year. His visits lasted a week at a time. In those years he assessed approximately 1 500 children and operated on about 600. For the first 15 years, the operations were almost exclusively soft tissue surgery: tendon lengthening, tendon transfers and clubfoot releases. As the facilities in Umtata were upgraded, he performed an increasing amount of bone surgery. The operations he did were mainly on the lower limbs. They included lengthening of the triceps surae at the level of the gastrocnemius, lengthening of the tendo Achillis, release of hamstrings and hip adductors, recession of iliopsoas recession at the hips and Souter slides. On the upper limbs he fairly regularly performed surgical release of the first web space and release of flexor carpi ulnaris. He closely supervised the postoperative care provided by the school, which always had at least one expert Bobarth trained physiotherapist in residence.
Between 1997 and 2000, internal arthrodiastasis procedures (endo-apparatus), using an internal skeletal distraction device, were performed on 33 young patients who had reached the point of total hip arthroplasty or arthrodesis. The mean age of the 20 males and 13 females was 19 years (range 11 to 51 years). We removed 19 implants, eight after completion of treatment or because they had outlived their usefulness, and 11 because no improvement in the hip disorder had been achieved. Good results were achieved in two thirds of the patients, including patients suffering from avascular necrosis of the femoral head, old Perthes’ disease and contained hip dysplasia with joint space narrowing and pain. Chondrolysis and stiffness of the hip appear to be contraindications for this type of treatment. The three post-traumatic hip disorders were probably also not ideal cases. In young patients, the results of total hip arthroplasty after trauma are poor, and the indications for internal arthrodiastasis should be redefined.
