Natural history of knee contractures in myelomeningocele

Anterior Distal Femoral Hemiepiphysiodesis in Children With Fixed Knee Flexion Deformities: Does Screw Position Matter?

BACKGROUND

Anterior distal femoral hemiepiphysiodesis (ADFH) using 2 percutaneous screws is an effective technique for the treatment of fixed knee flexion deformities in children with neuromuscular disorders. The role of sagittal screw position on the outcome of the procedure is unknown.

METHODS

This is a retrospective case series of patients who underwent ADFH at a single pediatric hospital from 2013 to 2020. Radiographs were evaluated for sagittal screw position and the associated change in lateral distal femoral physeal angle over time. The position of the 2 screws was classified as either being both in the anterior third of the physis (AA), one screw in the anterior third and the other screw in the middle third (AM), or both screws in the middle third of the physis (MM).

RESULTS

The study population included 68 knees in 36 patients. The mean physeal angle at the time of surgery was 93 degrees (SD 4.0 degrees), which increased to 102.4 degrees (SD 5.7 degrees) at 12 months, for a change of 9.4 degrees ( P <0.001). At 24 months, the mean physeal angle was 104.6 degrees (SD 6.3 degrees) for a further change of 2.9 degrees ( P <0.001). When stratified by screw position all screw configurations resulted in an increase in the physeal angle at 12 months. At the 24-month follow-up, the physeal angle in knees with AA screws continued to increase another 3.5 degrees ( P <0.05), there was a minimal change in knees with AM screws (1.47°, P >0.05) and knees with MM screws saw a reversal of physeal angle change (-7.1 degrees, P <0.05).

CONCLUSIONS

ADFH using percutaneous screws results in an increase in the lateral distal femoral physeal angle. The rate of correction is largest in the first 12 months after the procedure. As such, this procedure should be considered in patients with less than 2 years of growth remaining. However, initial screw positioning influences the amount of change over time, and close postoperative surveillance until physeal closure is essential for all patients.

LEVEL OF EVIDENCE

Level IV-retrospective case series.

Distal Femur Anterior Hemiepiphysiodesis for Fixed Knee Flexion Deformity in Neuromuscular Patients: A Systematic Review

BACKGROUND

In the past decade, distal femur anterior hemiepiphysiodesis for fixed knee flexion deformity has gained popularity. In this study, we aim to systematically review the literature on this technique as a treatment for fixed knee flexion deformity in patients with neuromuscular disorders.

METHODS

A systematic review was performed in the following databases: PubMed, Embase, and Medline. The inclusion criteria included anterior hemiepiphysiodesis of the distal femur for patients with neuromuscular disorders and fixed knee flexion deformities.

RESULTS

Our search yielded 419 titles. A total of 12 articles were qualified for final review based on the inclusion and exclusion criteria. The total number of patients was 279, with 483 knees corrected. The male to female ratio was 2.1:1, and the mean age of the patients was 11.3 ± 1.4 years (range 4-17 years). The mean preoperative flexion deformity was 23.1° ± 10.0° (range 10°-90°). The mean residual flexion deformity at the final follow-up was 8.6° ± 9.0° (range 0°-32.5°), which corresponds to a statistically significant decrease compared with the preoperative deformity (p < 0.05).

CONCLUSION

Anterior hemiepiphysiodesis for fixed knee flexion deformity provides favourable outcomes with low complication rates in patients with neuromuscular disorders. Future studies should focus on comparing the long-term outcomes of the different metal implants used for these operations.

LEVEL OF EVIDENCE

Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of plate and screw constructs versus screws only for anterior distal femoral hemiepiphysiodesis in children

The study aim was to compare methods of anterior distal femoral hemiepiphysiodesis (ADFH) for treatment of fixed knee flexion deformities in ambulatory children with neuromuscular conditions and flexed knee gait. This is a retrospective review of 47 children (14 female, 33 male, age at surgery: 12.1 ± 2.7 years) who underwent ADFH between 2009 and 2016. Subjects were grouped by ADFH construct: one transphyseal screw (N = 11), two transphyseal screws (N = 28) or plates and screws (P/S group, N = 8). Clinical/radiographic variables were analyzed using paired t tests, χ tests, multiple regression and analysis of covariance. Participants experienced significant reduction in knee flexion contractures (Δ12°, P < 0.006), with no difference among groups (P = 0.43). Postoperative knee pain was significantly more prevalent in the P/S group (5/8, 63%) than the 1-SCR group (0/11, 0%) and the 2-SCR group (2/28, 7%) (P = 0.002). ADFH results in significant reduction of knee flexion deformity and improved knee extension during gait. Plate and screw constructs, the 1 and 2 transphyseal screw techniques are equally effective, but plate and screw constructs may be associated with a higher risk of persistent postoperative knee pain.

Awareness, potential factors, and post-amputation care of stump flexion contractures among transtibial amputees

Objectives

This study aims to assess the level of awareness of transtibial amputee patients on stump contractures and their compliance with efforts implemented to prevent the condition.

Patients and methods

This study included 50 unilateral transtibial amputees (26 males, 24 females; mean age 55.4±14.7 years; range, 18 to 78 years) who met the respondent criteria of the study. The respondents were randomly selected and were issued with a questionnaire.

Results

The majority of the transtibial amputees were aware of stump contracture complications. It was found that they also preferred methods of prevention which required less effort, was cost-effective, and were also practical.

Conclusion

More focus should be placed on contracture prevention methods which were most complied with by the patients. This is because the effectiveness of a prevention method is highly influenced by patients' compliance with the method. Patients with a higher risk of developing stump contractures should be also given more attention in post-amputation care.

[Orthopedic management of spina bifida]

BACKGROUND

Spina bifida is associated with congenital deformities, such as kyphosis, spinal malformations, teratological hip dislocations, clubfeet, vertical talus and also with acquired deformities due to muscle imbalance and impaired biomechanics. The degree of the acquired deformities and the mobility of the patient depend on the level of the spinal lesion.

DIAGNOSTICS

Neurological symptoms are mostly asymmetric and there is an inconsistent correlation between the anatomical level of the lesion and muscle function. Deficits of sensation are usually one to two levels lower than the motor level. An exact neurological diagnosis should not be made before the second or third year of life and an early prognosis about walking ability should be avoided. The level L3 and therefore function of the quadriceps is a functional milestone after which modified independent ambulation with the use of ankle foot orthoses (AFO) and crutches is possible.

THERAPY

The basic principle is to support verticalization and gait even when loss of ambulation is later expected. It is also important to support and maintain sitting ability for high lesions, if necessary with correction of the spinal deformity. Findings in gait analysis have shifted the focus of treatment from radiological criteria to functional improvement, thus maintenance of the flexibility of the hip is the main goal of hip surgery. Reduction of the hip often leads to stiffness and has a high redislocation rate. Clubfoot deformities should be treated early and foot arthrodesis and stiffness have to be avoided. Another focus is the prevention of joint contracture by early prophylactic treatment.

CONCLUSION

The purpose of management is to maximize the functional potential of the child. Subjective well-being, absence of pain, mobility and socialization are the main goals. This does not necessarily imply ambulation; nevertheless, verticalization and associated orthotic management is one major objective of the orthopedic management of spina bifida.

Treatment of fixed knee flexion deformity by anterior distal femoral stapling

PURPOSE

The treatment of fixed knee flexion deformity through anterior distal femoral stapling has been investigated in only two studies so far, with promising results. The aim of the present study was to determine whether this technique might improve fixed knee flexion deformity in a series of growing children and adolescents with different conditions. Follow-up examinations were continued after staple removal in terms of a possible impairment of this deformity.

METHODS

We reviewed the medical records of all patients with fixed knee flexion deformity who had been treated by anterior distal femoral stapling at our institution. Twenty patients (37 knees) with a mean age of 12.7 years met the inclusion criteria (>12 months of follow-up; no additional procedures to correct fixed knee flexion deformity such as hamstring lengthening or posterior capsulotomy) and were evaluated in this study.

RESULTS

The mean fixed knee flexion deformity significantly improved from 21.4° (SD = 11.6) preoperatively to 7.0° (SD = 9.8) after a mean follow-up of 35.3 months. Young patients (<12 years) revealed superior improvement of this deformity, and especially children with distinct fixed knee flexion deformity of 30° or greater had benefit from early treatment. Impairment of flexion deformity was only seen in one patient (2 knees) after staple removal.

CONCLUSIONS

Our results demonstrate that anterior distal femoral stapling is an effective method for the treatment of fixed knee flexion deformity in growing children and adolescents. Rare complications, immediate mobilization, and a low recurrence rate after staple removal provide obvious advantages of this minimally invasive procedure.

LEVEL OF EVIDENCE

Retrospective therapeutic study, Level IV.

Anterior distal femoral hemiepiphysiodesis in the treatment of fixed knee flexion contracture in neuromuscular patients

AIM

Patients with neuromuscular diseases such as cerebral palsy (CP) and meningomyelocele (MMC) are prone to develop fixed knee flexion contracture. Distal femoral extension osteotomy allows acute correction of the deformity, but it is an extensive surgical procedure, and the complication rate is rather high. Immobilization can prolong the rehabilitation period, and may even result in deteriorated walking ability. The aim of this retrospective study was to evaluate the results of using anterior hemiepiphysiodesis of the distal femur to treat fixed flexion contracture of the knee.

MATERIALS AND METHODS

We studied 21 patients in our department from 2003 to 2009. Mean age was 10 years (5-15). Twelve suffered from MMC, five from CP, two from arthrogryposis, one had an enzyme defect, and one had Down's syndrome. Thirteen patients had a bilateral and eight a unilateral procedure. None of the patients underwent any other procedures. Two staples or 8-plates were inserted using two parapatellar incisions. Nine were operated on with staples and 12 with 8-plates. The plates or staples were removed when the desired effect of full knee extension was achieved or the patient reached skeletal maturity.

RESULTS

Mean fixed flexion contracture was 20° (10°-40°). Staples or 8-plates were removed after a mean of 24 (6-42) months. Mean fixed flexion contracture at removal was 10° (0°-30°). Two complications were seen: one infection and one supracondylar fracture.

CONCLUSION

Anterior distal femoral hemiepiphysiodesis using 8-plates or staples seems to be effective for correcting fixed knee flexion deformity in skeletally immature individuals. The complication rate is low (10 %). Our results are comparable to those of Kramer, Klatt, and Stevens. This procedure should be the primary treatment for fixed knee flexion contractures in neuromuscular patients with sufficient remaining growth.

Anterior femoral epiphysiodesis for the treatment of fixed knee flexion deformity in spina bifida patients

BACKGROUND

Fixed knee flexion deformity is a common problem in spina bifida patients. Owing to interference with ambulation, this deformity may lead to anterior knee pain and progressive crouch gait. If conservative treatment fails, surgical procedures including supracondylar femoral extension osteotomy, joint distraction, and posterior capsulotomy have to be considered. Potential complications of these procedures are fractures, neurovascular lesions, knee instability, and recurrent deformity with continued growth. As fixed knee flexion deformity in spina bifida patients frequently occurs bilaterally, this results in higher perioperative and postoperative risks and prolonged recovery, making these relatively invasive methods less appealing. In the skeletal immature patient, anterior femoral stapling is a feasible method to treat fixed knee flexion deformity as could be shown in an earlier study. In this study, anterior femoral stapling was performed in a series of patients with diverse etiologies, and the overall success rate was then calculated. The aim of this study was to determine whether anterior femoral epiphysiodesis may improve fixed knee flexion deformity in a group of spina bifida patients.

METHODS

Ten spina bifida patients with bilateral fixed knee flexion deformity (20 knees) were treated by anterior femoral epiphysiodesis through stapling. None of the patients received further knee procedures. The mean preoperative fixed knee flexion deformity was 20.3 ± 9.9 degrees (range: 10 to 40 degrees). Clinical and radiographic follow-up examinations were performed every 3 to 6 months after surgery.

RESULTS

All patients except 1 experienced significant improvement with a mean correction rate of 0.9 ± 0.5 degrees per month (range: 0.2 to 1.9 degrees). The residual flexion deformity averaged 5.3 ± 5.3 degrees (range: 0 to 15 degrees; P<0.001).

CONCLUSIONS

Anterior femoral epiphysiodesis through stapling is an effective and safe method for the treatment of fixed knee flexion deformity in growing children and adolescents with spina bifida.

LEVEL OF EVIDENCE

Therapeutic Study, Level IV.

Guided growth for fixed knee flexion deformity

BACKGROUND

Fixed knee flexion deformity (FKFD) is an insidious problem that may complicate the management of patients with neuromuscular compromise due to cerebral palsy, spina bifida, arthrogryposis, and other conditions. The energy costs associated with crouch gait may become prohibitive and, with the inexorable progression of fixed knee flexion, secondary pain may ensue as a result of fragmentation of the patella and/or tibial tubercle. Concomitant or compensatory flexion deformity of the hips and lumbar lordosis may develop, along with "pseudo equinus" of the ankles. Recommended treatments for FKFD have included bracing; physical therapy; and, in recalcitrant cases, distal femoral osteotomy, posterior release, or frame distraction. However, these latter modalities are fraught with potential complications including neurovascular damage, loss of fixation, undercorrection malunion, fracture, and recurrent deformity. Considering that FKFD is often bilateral, the complication risks for a given patient are doubled. In a previous study, the senior author reported successful hemiepiphysiodesis of the distal anterior femur using staples. However, further experience has demonstrated some of the limitations of stapling including relatively slow correction and occasional hardware migration. This led to the development of a more versatile and reliable solution using a pair of anterior tension band plates.

METHODS

In this retrospective clinical study, we are reporting this new technique of promoting gradual correction through guided growth of the distal femur, using a pair of anterior 8-plates. The correction is accomplished simultaneously and bilaterally, without immobilization, and may be combined with other operative procedures as indicated. We reviewed the charts, radiographs in a group of patients treated accordingly.

RESULTS

In this group of 18 patients with 29 deformities, we noted correction averaging 1.3 degrees (range, 0.0 [1 patient]-4.8 degrees), with minimal complications. No inadvertent coronal plane deformities were created. Upon full correction, the plates were removed so as to avoid recurvatum.

CONCLUSION

As an alternative to posterior capsulotomy or supracondylar extension osteotomy, we have found that guided growth is an effective and safe method of gradually correcting FKFD in growing children and adolescents.

LEVEL OF EVIDENCE

4 (retrospective clinical series).

Meningomyelocele: management in utero and post natum

We report a four year follow-up of 39 of 47 infants born after pre-labour Caesarean section and 68 of 79 born vaginally. Loss of motor function due to late complications was more frequent in the Caesarean section group (Fisher's Exact; P = 0.004). However, the means of the differences between the X-ray levels (measured as the last intact vertebral arch seen on standard anteroposterior roentgenograms of the spinal column) subtracted from the motor levels still favour Caesarean section (mean = 3.24; SD = 2.7) over vaginal delivery (mean = 1.2; SD = 2.7) (Student's t-test; P = 0.0003). The frequencies of other complications, death and neonatal meningitis, were not significantly different. Another 38 infants born by Caesarean section after labour were more paralysed (mean of X-ray and motor difference = 1.8, SD = 2.2) following rupture of amniotic membranes than those with intact amniotic membranes with or without labour (mean = 3.4; SD = 2.2) (Student's t-test; P = 0.0067). The differences between X-ray and motor levels for patients born by Caesarean section with intact amniotic membranes and without labour (mean = 3.6; SD = 2.4) were not significantly different from those with labour and intact amniotic membranes (mean = 2.89; SD = 1.5). The number of new cases of meningomyelocele presenting to our clinic has decreased from an average of 30 per year between 1970 and 1987 to 14 between 1988 and 1992.

The epidemiology of major joint contractures: a systematic review of the literature

Current knowledge on the epidemiology of major joint contractures is limited. We systematically reviewed the literature to identify studies examining the epidemiology of joint contracture regardless of clinical condition. Epidemiologic measures of interest were prevalence, incidence, and prognostic risk factors. We used Medline to identify all epidemiologic studies of major joint contractures published from 1966 to March 2005. There was a high prevalence of major joint contractures. Most studies focused on one joint rather than including all relevant major contractures. However, most studies did provide a definition of a contracture or the measures used to assess contractures. Immobility is a highly prevalent disability in at-risk populations, and constitutes a tremendous burden to patients in nursing homes, hospitals, and the outpatient community. The lack of epidemiologic data is a major impediment to providing appropriate treatment.

Crouched gait in myelomeningocele: a comparison between the degree of knee flexion contracture in the clinical examination and during gait

The purpose of this study was to quantitatively evaluate, in patients with low lumbar and sacral level myelomeningocele who have knee flexion contractures, whether there are significant differences between the degree of knee flexion contracture measured clinically and the degree of actual knee flexion during gait, measured by computerized gait analysis. Patients were divided into two groups, those who walked with ankle-foot orthoses (AFOs) alone and those who walked with AFOs and crutches. In both groups, the patient's knee flexion contractures were measured clinically, and the degree of knee flexion was measured dynamically at two representative points in the gait cycle. In both groups and at both points of the gait cycle, the degree of knee flexion during gait was significantly greater than the degree of clinical knee flexion contracture. This should be taken into account when evaluating the crouch gait of children with myelomeningocele and planning the proper treatment.

The influence of spasticity in the lower limb muscles on gait pattern in children with sacral to mid-lumbar myelomeningocele: a gait analysis study

Gait analysis and recording of standing position were performed in 38 ambulatory children with myelomeningocele. Thirty-four were independent ambulators and four required a walking aid. All subjects were assigned one of four muscle function groups based on muscle strength. They were also divided into subgroups based on the distinction between flaccid and spastic paresis in the lower limb joints. A comparison was made between the gait pattern of the children with spasticity and that of the children with flaccid paresis in each muscle function group. Spasticity in only the ankle joint muscles influenced the subject's gait and standing position compared to the subgroups with a flaccid paresis. Even larger deviations in gait and standing position were observed when spasticity occurred in muscles at the knee and hip joints. When setting ambulatory goals the presence of additional neurological symptoms such as spasticity and inadequate balance should be taken into consideration.

Neonatal kyphectomy in the patient with myelomeningocele

STUDY DESIGN

A retrospective cohort study was used to investigate a group of neonates with myelomeningocele who had a kyphectomy performed in conjunction with dural sac closure during the first few days of life.

OBJECTIVES

To assess the effectiveness of operative intervention in the neonatal period to correct the kyphotic deformity in the patient with myelomeningocele and to monitor its long-term results.

SUMMARY OF BACKGROUND DATA

Orthopedic management originally focused on the immediate treatment of the kyphotic deformity in the infant with myelomeningocele. However, there has been a movement toward postponing surgical treatment of the kyphos until a later age. This study included the longest follow-up of the largest group of neonates that a single surgeon has managed surgically since the treatment of this condition was originally described.

METHODS

The radiographic and clinical results for all neonates treated with a kyphectomy at the time of myelomeningocele closure between 1980 and 2000 were analyzed.

RESULTS

Neonatal kyphectomy was performed on nine males and two females. The average preoperative kyphotic angle measured 67 degrees. The average initial correction was 77 degrees, and the average loss of correction at follow-up assessment was 55 degrees. There were no serious complications, and wound closure was successful in all patients. One patient required a repeat kyphectomy and posterior spinal fusion at the age of 9 years and 2 months. The average follow-up period was 7 years and 4 months (range 44-174 months).

CONCLUSIONS

Kyphectomy performed at the time of dural sac closure in the neonate is a safe procedure with excellent initial correction. Eventual recurrence is expected despite the procedure. However, it occurs in the form of a longer, more rounded deformity that is less technically demanding.

Orthopaedic care of children with spina bifida: you've come a long way, baby!

The prognosis of children born with spina bifida has dramatically changed in the past several decades. Children with spina bifida with appropriate medical care can now expect to live into adulthood. Orthopaedic care of children with spina bifida has evolved to increase function, promote long-term mobility, and improve overall health. This article looks at current orthopaedic treatment against the backdrop of historical care. Treatment of the foot, knee, hip, and spine are reviewed, as well as neurologic implications. Issues of ambulation, orthotics, assistive devices, and insensate skin are addressed.