Aims. In order to release the contracture band completely without damaging normal tissues (such as the sciatic nerve) in the surgical treatment of gluteal
Purpose of this study is to create an experimental model on rats for EMG evaluation of the supraspinatus muscle after traumatic rupture of its tendon. The population of this study consisted of 5 male rats of 300–400g. Under general anaesthesia we proceeded with traumatic rupture of the supraspinatus tendon and exposure of the muscle. The electrode of a stimulator was placed under suprascapular nerve and the supraspinatus tendon was sutured on a transducer for digital record of the produced signal. Initially we found the resting length and the electric intensity for higher
Knee stiffness is a well-recognised postoperative problem that has been reported to occur in 6% to 15% of all patients who undergo total knee arthroplasty (TKA), and there are multiple preoperative, intraoperative, and postoperative risk factors that may predispose patients to postTKA knee stiffness. Preoperative risk factors include poor baseline range of motion (ROM), obesity, and a history of previous knee surgery and/or trauma. Potential intraoperative risk factors for having a stiff knee are malalignment, gap imbalance, and under-resection of patella. Possible postoperative risk factors include heterotopic ossification, pain, poor patient motivation, and poor physical therapy compliance. Three commonly used adjuvant treatments for this condition are custom knee devices, Botox, and ASTYM. These treatment modalities are most effective when used within 6 weeks after surgery. Multiple case series have reported that CKD can improve range of motion while maximising patient-reported functional outcomes. Botox can improve range of motion by paralyzing the muscle where the contracture is located. ASTYM therapy has recently been reported to resolve
1. Contracture of parts of the quadriceps muscle is not uncommon and is often accompanied by tightness of the ilio-tibial tract. It is suggested that this may follow intramuscular injections. 2. Recurrent dislocation of the patella can be a consequence of this
1. Six patients are reported in whom ischaemic
Hallux rigidus was first described in 1887. Many aetiological factors have been postulated, but none has been supported by scientific evidence. We have examined the static and dynamic imbalances in the first metatarsophalangeal joint which we postulated could be the cause of this condition. We performed a finite-element analysis study on a male subject and calculated a mathematical model of the joint when subjected to both normal and abnormal physiological loads. The results gave statistically significant evidence for an increase in tension of the plantar fascia as the cause of abnormal stress on the articular cartilage rather than mismatch of the articular surfaces or subclinical
Painful peroneal spastic flatfeet without coalition or other known etiologies in adolescence, remains a difficult condition to treat. We present eight such cases with radiological and surgical evidence of bony abnormalities in the lateral subtalar region just anterior to the posterior facet. All patients had presented as tertiary referrals with recalcitrant pain and had undergone a trial of orthotics and physiotherapy. Diagnostic workup included a clinical and radiographic evaluation. Clinical examination consisted of gait examination, foot alignment, range of motion, torsional profile of the lower limbs and marking of symptomatic foci. All patients had standing weightbearing anteroposterior and lateral projections of the foot and ankle, CT and/or MRI scans of the foot. Coalitions and other known intra-articular pathologies like subtalar arthritis were ruled out. All patients had bilateral flatfeet but unilateral peroneal spasm. All patients had an accessory anterolateral talar facet (ATF) which was arising as an anterior and distal extension of the lateral process of the talus. This caused lateral impingement between the facet and the calcaneum, confirmed by bone edema around the sinus tarsi and marked at the apex of the angle of Gissane on MRI scans. All patients had stiff subtalar joints with very limited movement under anaesthesia, indicating peroneal
Peroneal spastic flatfeet without coalition or other known etiologies in adolescence remain a challenge to manage. We present eight such cases with radiological and surgical evidence of bony abnormalities in the subtalar region just anterior to the posterior facet. All patients had presented as tertiary referrals with recalcitrant pain and had undergone a trial of orthotics and physiotherapy. Diagnostic workup included a clinical and radiographic evaluation. Clinical examination consisted of gait examination, foot alignment, range of motion, torsional profile of the lower limbs and marking of symptomatic foci. All patients had standing weightbearing AP and lateral projections of the foot and ankle. CT and/or MRI scans of the foot were performed in axial coronal and saggital planes. Coalitions and other intraarticular known pathologies were ruled out. All patients had bilateral flatfeet but unilateral peroneal spasm. All patients had an accessory talar facet in front of the posterior subtalar facet. This caused lateral impingement between the facet and the calcaneum, confirmed by bone edema around the sinus tarsi. All patients had stiff subtalar joints with very limited movement under anaesthesia, indicating peroneal
Objective: To evaluate the effectiveness of distal rectus femoris (RF) release versus transfer to treat gait abnormalities of the knee in ambulatory children with cerebral palsy. Methods: Ninety-three children were included in this study. Thirty-two patients underwent RF transfer at a mean age of 11.8 years and sixty-one underwent distal RF release at a mean age of 12.5 years. Indications for surgery included RF contractures, abnormal RF activity during swing phase (EMG) and kinematic characteristics of stiff-knee gait. All patients had pre–and postoperative 3D gait analysis and EMG at one year follow up. To evaluate outcomes, patients were grouped by pre-operative knee kinematics (swing-phase peak knee flexion (PKF) <
50º or PKF >
50º occurring later than 77% of the cycle). All data was analyzed statistically. Results: For the group of patients with PKF<
50º, this value increased significantly after RF transfer (p=.005) and after RF release (p=.03). Children with PKF later than 77% of the cycle also showed significant improvement after both procedures (p=.001; p=.02). All patients experienced a significant decrease of
We describe the long-term results in ten patients with obstetric brachial plexus palsy of anterior shoulder release combined with transfer of teres major and latissimus dorsi posteriorly and laterally to allow them to act as external rotators. Eight patients had a lesion of the superior trunk and two some involvement of the entire brachial plexus. The mean age at operation was six years, and the mean follow-up was 30 years. Before operation, the patients were unable actively to rotate the arm externally beyond neutral, although this movement was passively normal. All showed decreased strength of the external rotator, but had normal strength of the internal rotator muscles. Radiologically, no severe bony changes were seen in the glenohumeral joint. No clinically detectable improvement of active abduction was noted in any patient. The mean active external rotation after operation was 36.5°. This was maintained for a mean of ten years, and then deteriorated in eight patients. At the latest follow-up the mean active external rotation was 10.5°. The early satisfactory results of the procedure were not maintained. In the long term there was loss of active external rotation, possibly because of gradual degeneration of the transferred
Purpose: Congenital idiopathic clubfoot is the most common musculoskeletal birth defect developing during the fetal period, but with no known etiology. MYH 2, 3, 7, and 8 are expressed embryonically or perinatally, the period during which congenital idiopathic clubfoot develops; are all components of Type II muscle, which is consistently decreased in clubfoot patients; and are associated with several
Purpose of this study is to create an experimental model of electrophysologic evaluation of the supraspinatus muscle on rats, after traumatic rupture of its tendon. The population of this study consisted of 10 male Sprague Dawley rats weighting 300–400g. Under general anaesthesia we proceeded with traumatic rupture of the supraspinatus tendon and exposure of the muscle. The scapula was immobilized, and the supraspinatus tendon was attached to a force transducer using a 3–0 silk thread. A dissection was performed in order to identify the suprascapular nerve, which was then stimulated with a silver electrode. Stimulations were produced by a stimulator (Digitimer Stimulator DS9A) and were controlled by a programmer (Digitimer D4030). Fiber length was adjusted until a single stimulus pulse elicited maximum force during a twitch under isometric conditions. Rectangular pulses of 0.5 ms duration were applied to elicit twitch contractions. During the recordings, muscles were rinsed with Krebs solution of approximately 37 8C (pH 7.2–7.4) and aerated with a mixture of 95% O2 and 5% CO2. The output from the transducer was amplified and recorded on a digital interface (CED). The following parameters were measured at room temperature (20–21 8C): single twitch tension; time to peak; half relaxation time; tetanic tensions at 10, 20, 40, 80 and 100 Hz; and fatigue index, which was evaluated using a protocol of low frequency (40 Hz) tetanic contraction, during 250 ms in a cycle of 1 s, for a total time of 180 s. The fatigue index value was then calculated by the formula [fatigue index=(initial tetanic tension − end tetanic tension) ∗ 100/(initial tetanic tension)]. In the end, the transducer was calibrated with standard weights and tensions were converted to grams. The mean single twitch was 8.2, the time to peak 0.034 msec and the half relaxation time 0.028 msec. The strength of titanic
Introduction: Gastrocnemius contracture, as demonstrated by Silfverskiold’s test, is increasingly recognised as an underlying cause of painful disorders of the foot and ankle. Elevated pressure beneath the forefoot and symptoms in the hindfoot and ankle are produced as a result of the biomechanical imbalance. Adaptive shortening of the gastrocnemius can be treated by a supervised stretching program. Night splintage and serial casting are other useful non-operative treatments. Refractory cases may be considered for surgical release of the gastrocnemius. Materials and Methods: The purpose of this study was to follow-up all those patients who were treated with a medial proximal gastrocnemius release with a minimum follow-up of six months. Results: Eighty procedures were performed in sixty-five patients. There was one post operative infection. One patient has diminished sensation in the distribution of a branch of the saphenous nerve. There was an improvement in ankle dorsiflexion with the knee extended in all patients. Those patients with heel pain felt their symptoms had improved in the majority of cases. Discussion: Release of the gastrocnemius aponeurosis at the gastrosoleus junction may be performed open or endoscopically. Both techniques place the sural nerve at risk of injury. Proximal release of the gastrocnemius is an alternative technique. Proponents of this method release both the medial and lateral heads through a single transverse skin incision over the popliteal fossa. It has been postulated that release of the medial head alone is sufficient to overcome the
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
Aim: To evaluate the effectiveness of distal rectus femoris (RF) release versus transfer to treat gait abnormalities of the knee in ambulatory children with cerebral palsy. Patients &
Methods: Thirty-nine children were included in this study. Thirty patients (55 limbs) underwent RF transfer at a mean age of 11.8 years. and nine (16 limbs) underwent distal rectus release at a mean age of 12.5 years. Indications for surgery included RF contracture and abnormal activity during swing phase in dynamic electromyography (EMG), whether with the presence of kinematic characteristics of stiff-knee gait or not. All patients had pre- and postoperative gait analysis and EMG. To evaluate functional outcomes, patients were grouped by pre-operative knee kinematics (normal; swing-phase peak knee flexion (PKF) <
50°; and peak knee flexion >
50° happening later than 77% of the cycle). All data was analyzed statistically. Results: For the group of patients with PNF<
50°, this value increased significantly after rectus transfer (p=.005). Children with PNF>
50° and later than 77% of the cycle, showed significant improvement in timing after both procedures (p=.001; p=.02). When kinematic parameters were normal before surgery, they did not improved, although patients experienced a significant decrease of
Free, vascularised fibular grafting is well described in limb salvage surgery. The mechanical properties of the fibula make it ideal for replacement of bony defects after tumour resection and it can be sacrificed with minimal morbidity. We review the outcome of a consecutive series of 24 patients. Between 1993 and 2002 we performed free vascularised fibular grafts in 24 patients as part of a limb salvage procedure following tumour excision. Pre-operatively patients were staged using the Musculoskeletal Tumour Society (MSTS) system. Post-operatively patients were followed up with radiographs and clinical examination. From the radiographs graft hypertrophy and time to bony union was documented. Functional outcome was assessed using the MSTS scoring system. Complications were recorded. There were 15 women and 9 men with a mean age of 26 years (6–52). Mean follow up was 51 months (12–106). There were 19 malignant tumours, all stage 2b, and 5 giant cell tumours. The mean length of graft was 12.5 cm. (4.5–25). 16 grafts were used in the upper limb and 8 in the lower limb. Arthrodesis was performed in 8 cases and intercalary reconstruction in 16 cases. Fixation of grafts was achieved with a plate and screws in 21, a blade plate in 2 and an IM nail in 1. In 6 cases the resected tumour bone was reinserted as autograft after extracorporeal irradiation. In all but one patient the tumour margins were clear. Primary bony union was achieved in 22 patients (92%) at a mean of 35 weeks (12–78). Graft hypertrophy was seen in 7/29 cases (24%). Complications included 2 wound breakdowns, 3 stress fractures, 1
The Gibson and Moore postero-lateral approach is one of the most often used in hip replacement. The advantage of this approach is an easy execution but it's criticized because of its invasivity to muscle-tendinous tissues especially on extrarotators muscles and because of predisposition to posterior dislocation. Since June 2003 we executed total hip replacements using a modified postero-lateral approach which allows to preserve the piriformis and quadratus femoris muscles and to detach just the conjoint tendon (gemelli and obturator internus). Articular capsule is preserved and it will be anatomically sutured at the end of the procedure as well as the conjoint tendon with two transossesous sutures. Piriformis and quadratus femoris muscles result untouched by this approach. We have executed 500 surgeries with this modified approach. We have used different stems (straight, anatomical, modular and short) and press fit acetabular cup with polyethylene or ceramic insert and we have always used 36 mm femoral heads when allowed by the cup dimensions. We have used any size both of stems and cups without limitation due to the surgical approach. The mean age is 61.8 y.o., 324 females and 176 males. Obese patients, hip dysplasia Crowe 3 and 4 and post traumatic arthrosis are exclusion factors for the execution of this approach. If possible we have maintained the capsulo-tendinous less invasivity. The BMI is not an excluding factor because it's just the gluteus region that is an important factor to decide if to execute or not a less invasive approach. Analyzing our 500 cases we didn't have any case of malpositioning of the stem in varus or valgus (more than 5°) and considering acetabular cup we had the tendency to position it in valgus position (not more than 40°) in the first 20 cases. No leg discrepancy more than 1 cm were observed. Intra-operative blood loss have been reduced of about 30 % and 50% in the post-operative. All the patients were able to active hip mobilization within the first day after surgery with a mean range of motion of 0-70°. The patients were mobilized the first day after surgery and 80% of them were able to assisted walk within second day after surgery. The mean time of stay in hospital was 6.8 days. After 4 weeks 98% of the patients were able to walk without crutches. One case of deep infection were evaluated and then solved with surgical debridement; no wound dehiscence. We had 1 case of anterior hip dislocation in dysplastic arthrosis due to a technical mistake. In 1 case we had femoral nerve palsy, then solved, probably because of anterior retractor malpositioning. We had 5 cases of piriformis
Introduction Free, vascularised fibular grafting is well described in limb salvage surgery. The mechanical properties of the fibula make it ideal for replacement of bony defects after tumour resection and it can be sacrificed with minimal morbidity. We review the outcome of a consecutive series of 24 patients. Methods Between 1993 and 2002 we performed free vascularised fibular grafts in 24 patients as part of a limb salvage procedure following tumour excision. Pre-operatively patients were staged using the Musculoskeletal Tumour Society (MSTS) system. Post-operatively patients were followed-up with radiographs and clinical examination. From the radiographs graft hypertrophy and time to bony union was documented. Functional outcome was assessed using the MSTS scoring system. Complications were recorded. There were 15 women and nine men with a mean age of 26 years (6 to 52). Mean follow-up was 51 months (12 to 106). There were 19 malignant tumours, all stage 2b, and five giant cell tumours. The mean length of graft was 12.5 cm (4.5 to25). Sixteen grafts were used in the upper limb and eight in the lower limb. Arthrodesis was performed in eight cases and intercalary reconstruction in 16 cases. Fixation of grafts was achieved with a plate and screws in 21, a blade plate in two and an IM nail in one. In six cases the resected tumour bone was reinserted as autograft after extracorporeal irradiation. Results In all but one patient the tumour margins were clear. Primary bony union was achieved in 22 patients (92%) at a mean of 35 weeks (12 to 78). Graft hypertrophy was seen in 7/29 cases (24%). Complications included two wound breakdowns, three stress fractures, one
