Lower Extremity Contractures Research Articles

Ureteroscopy for urolithiasis in bedridden patients: it is feasible and acceptable.

To investigate the safety of transurethral ureteroscopy (URS) for urolithiasis in bedridden patients and to identify bedridden patient-specific risk factors for postoperative complications. The patients who underwent URS for urolithiasis were divided into bedridden patients and good performance status (PS) patients, and the groups were compared regarding their clinical characteristics and postoperative complications. A multivariable logistic regression analysis was performed to evaluate independent predictors of postoperative febrile urinary tract infection (fUTI). A total of 1626 patients were included, 276 in the bedridden patient group, and 1350 in the good PS patient group. The bedridden patient group had a significantly higher age and higher proportion of females and had multiple comorbidities. In 77 patients (27.9%), 88 postoperative complications developed for the bedridden patient group. Clavien-Dindo grade III or IV complications were observed in only 8 patients. No grade V complications were observed. The most common complication was fUTI. The frequency of fUTI with grade III or IV for the bedridden patient group (2.2%) was higher compared with the good PS patient group (0.5%), but the difference was not statistically significant (p = 0.13). Bedridden patient-specific risk factors for fUTI included female sex, diabetes mellitus, cerebrovascular comorbidities, lower extremity contracture, and prolonged operative time. URS for urolithiasis is a feasible and acceptable procedure in bedridden patients, despite the moderate rate of postoperative complications. The identified risk factors provide a framework for risk stratification and individualized care in this unique patient population.

Knee flexion compensation in postoperative adult spinal deformity patients: implications for sagittal balance and clinical outcomes.

To determine whether maintaining good sagittal balance with significant knee flexion (KF) constitutes a suboptimal outcome after adult spinal deformity (ASD) correction. This single-center, single-surgeon retrospective study, assessed ASD patients who underwent posterior spinal fusion between 2014 and 2020. Inclusion criteria included meeting at least one of the following: PI-LL ≥ 25°, T1PA ≥ 20°, or CrSVA-H ≥ 2cm. Those with lower-extremity contractures were excluded. Patients were classified into four groups based on their 6-week postoperative cranio-hip balance and KF angle, and followed for at least 2 years: Malaligned with Knee Flexion (MKF+) (CrSVA-H > 20mm + KFA > 10), Malaligned without Knee Flexion (MKF-) (CrSVA-H > 20mm + KFA < 10), Aligned without Knee Flexion (AKF-) (CrSVA-H < 20mm + KFA < 10), and Aligned with Knee Flexion (AKF+) (CrSVA-H < 20mm + KFA > 10). The primary outcomes of this study included one and two year reoperation rates. Secondy outcomes included clinical and patient reported outcomes. 263 patients (mean age 60.0 ± 0.9 years, 74.5% female, and mean Edmonton Frailty Score 3.3 ± 0.2) were included. 60.8% (160/263 patients) exhibited good sagittal alignment at 6-week postop without KF. Significant differences were observed in 1-year (p = 0.0482) and 2-year reoperation rates (p = 0.0374) across sub-cohorts, with the lowest and highest rates in the AKF- cohort (5%, n = 8) and MKF + cohort (16.7%, n = 4), respectively. Multivariable Cox regression demonstrated the AKF- cohort exhibited significantly better reoperation outcomes compared to other groups: AKF + (HR: 5.24, p = 0.025), MKF + (HR: 31.7, p < 0.0001), and MKF- (HR: 11.8, p < 0.0001). Our findings demonstrate that patients relying on knee flexion compensation in the early postoperative period have inferior outcomes compared to those achieving sagittal balance without knee flexion. When compared to malaligned patients, those with CrSVA-H < 20mm and KFA > 10 degrees experience fewer early reoperations but similar delayed reoperation rates. This insight emphasizes the importance of considering knee compensation perioperatively when managing sagittal imbalance in clinical practice.

Knee Strength and Ankle Range of Motion Impacts on Timed Function Tests in Duchenne Muscular Dystrophy: In the Era of Glucocorticoids.

Duchenne Muscular Dystrophy (DMD) is a neuromuscular disorder that presents in childhood and is characterized by slowly progressive proximal weakness and lower extremity contractures that limit ambulatory ability [1, 2]. Contractures develop in the ankles, knees, and hips due to muscle imbalances, fibrotic changes, loss of strength, and static positioning [2, 5]. Currently, standards of care guidelines emphasize the importance of maintaining good musculoskeletal alignment through stretching, bracing, and glucocorticoid (GC) therapy to preserve strength and function. This is a retrospective analysis of prospectively collected data through the CINRG Duchenne Natural history study (DNHS). The objectives of this analysis are to understand the progression of ankle contractures for individuals with DMD and to investigate the relationship between progressive lower limb contractures, knee strength, and Timed Function Tests.A collection of TFTs including supine to stand (STS), 10 meter walk test (10MWT), and timed stair climbing (4SC) have been used to monitor disease progression and are predictive of loss of ambulation in these patients [4]. Multiple factors contribute to loss of ambulation, including progressive loss of strength and contracture development that leads to changing biomechanical demands for ambulation. A better understanding of the changes in strength and range of motion (ROM) that contribute to loss of function is important in a more individualized rehabilitation management plan. In this longitudinal study, we measured strength using quantitative muscle testing (QMT) with the CINRG Quantitative Measurement System (CQMS)), ROM was measuresed with a goniometer and TFTs were measured using a standard stopwatch and methodology. We enrolled 440 participants; mean baseline age was 8.9 (2.1, 28.0) years with 1321 observations used for analysis. GC use was stratified based on duration on drug with 18.7%at < 6 months or naïve; 4.3%<1 year; 58.0%1 < 10 years; and 19.3%between 10-25 years of GC use. Ankle ROM was better for those on GC compared to GC naive but did not significantly influence long-term progression rates. QMT, ROM, age and GCs contribute to speed of TFTs. Knee extension (KE) strength and Dorsiflexion (DF) ROM are significant predictors of speed for all TFTs (p < 0.001). Of the variables used in this analysis, KE strength is the primary predictor of walking speed, estimating that every pound increase in KE results in a 0.042 m/s improvement in 10MWT, and a smaller similar increase of 0.009 m/s with every degree of ankle DF ROM. GC use provides an improvement in strength and ROM but does not affect rate of change. Knee strength has a greater influence on speed of TFTs than DF ROM, although both are statistically significant predictors of speed. Results show that retaining knee strength [1, 2], along with joint flexibility, may be important factors in the ability to perform walking, climbing and supine to stand activities.

Bruck syndrome: A rare case presentation with isolated lower extremity contractures and multiple postoperative peri-implant fractures

Bruck syndrome, characterized by congenital brittle bones and multiple joint contractures, is a rare variant of osteogenesis imperfecta. Here, we report the case of a 7-year-old male patient who presented with a fractured shaft of the femur following trivial trauma. He was diagnosed case of arthrogryposis multiplex congenital with deformities involving both knees and ankle. He had a history of bilateral femoral fractures during birth. Due to the knee contracture and a narrow canal, we fixed the fracture by plating. However, the patient developed peri-implant fractures proximal to the plate. Due to the presence of multiple peri-implant fractures and joint contractures, we diagnosed the patient with Bruck’s syndrome and initiated intravenous bisphosphonate therapy. Subsequently, the patient developed one more fracture in the contralateral femur. This case signifies the importance of screening all patients with multiple congenital contractures and recurrent fractures for Bruck syndrome.

Reconstruction of burn scar contracture deformity of the extremities using thin thoracodorsal artery perforator free flaps.

Severe burn scar contracture of the extremities, especially the joint areas, causes aesthetic problems and functional limitation. Release of burn scar contractures requires complete removal of the scars and resurfacing of the resulting defects. Here, we describe thoracodorsal artery perforator (TDAP) free flaps for reconstructing burn scar contractures. Between August 2013 and July 2018, 25 patients with severe burn scar contractures of the extremities underwent reconstruction using TDAP free flaps. Twelve were men and the mean age of the patients was 38.1 years (range, 12-66 years). Five patients had upper extremity contractures and 20 had lower extremity contractures. Twenty-one patients underwent reconstruction with a TDAP flap alone, while three received two perforator flaps, a TDAP and an anterolateral thigh flap or deep inferior epigastric artery perforator (DIEP) flap. The remaining patient received three perforator flaps, two TDAP and an anterolateral thigh flap. Fourteen patients had an improved range of motion after reconstruction. All the flaps survived except in the case of four patients who suffered partial loss of a TDAP flap. In one patient, there was partial skin graft loss at the donor site. The mean follow-up was 17.2months (range 6-36 months). Ideal reconstruction of burn scar contracture yielding functional and aesthetic results involves complete removal of scar tissue and reconstruction. Depending on the extent of the defect, the TDAP flap, with its thin and pliable tissue and minimal donor site morbidity, may be the best option for reconstruction of burn scar contracture.

38. Painless Labia Hair Tourniquet Presenting as a Recurrent Vulvar Mass

<h3>Background</h3> Hair tourniquets are a rare phenomenon effecting potentially any appendage. Male genitalia and digits are the most common locations with female genitalia classified as an "other" site, occurring in less than 6% of reported reviews. The most recent review of female genital hair tourniquets identified 34 patients from 32 reports or series. Pain was reported as a presenting symptom in 30 cases, while the remaining four cases did not comment on pain. We present a case of an asymptomatic labial hair tourniquet presenting as a vulvar mass. <h3>Case</h3> The patient is a 5-year 7-month female born at 24 weeks gestation with intraventricular hemorrhage and subsequent cerebral palsy (CP) and lower extremity contractures. The patient was referred by her PCP for possible biopsy due to a recurrent vulvar mass that waxed and waned in size and purple discoloration over two months. The patient was scheduled for exam under anesthesia and noted to have an edematous left labia minora (Fig 1) with tightly wound hair and cotton threads at the base leaving an erosion with an indentation flap in its mid portion (Fig 2). The fibers were released, a ‘V" excision was created removing the mid portion (Fig3), and the inferior and superior areas of the labia were approximated restoring symmetry. (Figs 4) The patient's postoperative course was uncomplicated and at 20 months post procedure her parents report normal anatomy without new incidents of labia edema. <h3>Comments</h3> This case report demonstrates a presentation of chronic painless swelling due to a labia hair tourniquet, which has not yet been described in the literature. Absence of pain may have led to a delay in referral for definitive diagnosis and treatment. It is possible that sensory disruptions in the lower extremities from CP contributed to the lack pain perception by the patient.

Trousseau’s sign and QT prolongation in hypocalcaemia

A 65-year-old woman presented to the hospital with severe weakness, muscle cramps and lower extremity contractures. She had a medical history of hypertension, atrial fibrillation and heart failure with preserved...

Effects of Whole-Body Vibration-Assisted Training on Lower Limb Blood Flow in Children With Myelomeningocele.

This study investigated the effectiveness of whole-body vibration (WBV) training incorporated into a conventional physiotherapy (PT) program (WBV-assisted training) in improving blood flow in the lower limbs and range of motion in the lower limb joints of children with myelomeningocele (MMC). A total of 31 children with MMC (7–15 years old) underwent a 6 weeks treatment program consisting of 2 weeks of conventional PT followed by 4 weeks of WBV-assisted training. The assessment comprised two parts: evaluation of lower limb joint range of motion and Doppler ultrasonography of the superficial femoral, popliteal, and anterior tibial arteries and was performed three times for each of the participants (at baseline, after 10 sessions of PT but before WBV-assisted training, and after 20 sessions of WBV-assisted training). Our results showed that WBV-assisted training significantly improved lower limb circulation in patients with MMC, increasing velocity and reducing resistivity in all tested arteries. Moreover, WBV-assisted training alleviated lower-extremity contractures, especially of the knee. Thus, WBV-assisted training is effective as an adjunctive rehabilitation program for improving functional mobility in children with MMC.

MON-359 Hollow Bones: A Case Report of Immobilization Osteoporosis in a Young Female

Introduction:Osteoporosis is defined as decreased bone strength due to reduced bone mineral density (BMD) and/or abnormal bone architecture leading to bone fragility and increased risk of pathologic fractures. Typically a disease of post-menopausal females, osteoporosis is uncommon in the young. We present a case of a 34-year-old woman, who was diagnosed with severe osteoporosis in the setting of prolonged immobilization.Clinical Case:A 34-year-old woman was admitted for treatment of bacteremia in the setting of IV drug use and right hip septic arthritis leading to femoral head osteonecrosis requiring a long course of antibiotic treatment and resulting in prolonged immobilization. She was readmitted 2 months later with septic shock and bilateral septic arthritis needing right hip replacement for source control. She developed multiple contractures of lower extremities due to prolonged immobility and was immobile for a total of 11 months despite significant physical therapy (PT) involvement. A few months into her hospital stay, she developed acute onset right ankle pain with no falls or trauma. Xrays showed right tibial metaphyseal fracture and severe demineralization of bones of lower extremities. History and physical exam showed no signs/symptoms of malabsorption, hyperthyroidism or Cushing’s syndrome. Laboratory evaluation showed calcium (Ca) of 11.8 mg/dL (8.5–10.4), parathyroid hormone (PTH) < 3 ng/dL (12–72), C-telopeptide (Ctx) 1806 pg/ml (60–650) and normal phosphate, TSH, prolactin, 25-hydroxy and 1,25-dihydroxy vitamin D levels. PTHrP (parathyroid hormone related peptide) was < 2 pmol/L. 24-hour urine Ca was 414 mg (50–150). Serum and urine protein electrophoresis showed no monoclonal spike. Gonadal profile showed estrogen 42 pg/dL, FSH 1 mU /mL, LSH 0.1 mU /mL. DEXA scan showed severe osteoporosis with T-score of -3.2 at both the left femoral neck and lumbar spine. Osteoporosis and hypercalcemia were attributed to protracted immobilization. Therapy was initiated with alendronate 70 mg weekly along with vitamin D. Teriparatide was not used due to high serum Ca. Repeat labs at 6 months showed good response to alendronate with Ca 9.6, PTH 58, 24 hr urine Ca 96 and Ctx 1092. Mobilization of patient and regular PT were performed.Conclusion:Osteoporosis in a young adult is a rare entity and demands evaluation for secondary causes. An important and overlooked cause of bone loss is immobility and decreased load development on bones. Bone is a piezoelectric material and immobilization causes negative bone turnover. Early physical mobility and weight bearing is the most effective method of reducing bone loss. Teriparatide, due to anabolic effects has an advantage over bisphosphonates. Romosozumab (anti-sclerostin antibody) and whole body vibration are also being studied for disuse osteoporosis. Calcium and vitamin D supplementation are essential.

Treatment of Foot Deformities in Arthrogryposis Multiplex Congenita

The term arthrogryposis is used to describe >300 conditions of differing etiologies and clinical manifestations that are characterized by generally nonprogressive congenital joint contractures of more than two different body areas, which occur in one per 3000 live births1,2. So-called classic arthrogryposis (amyoplasia or arthrogryposis multiplex congenita) constitutes about 30% of all congenital contractures and usually presents with severe, multiple upper and/or lower-extremity contractures and muscle weakness of variable intensity; in distal arthrogryposis—a subgroup of autosomal dominant conditions without underlying general neuromuscular pathology—the hands and feet are mainly affected, whereas contractures around proximal joints are absent or limited in their presentation3. Foot deformities are common in all types of arthrogryposis, especially amyoplasia (prevalence, 80% to 100%), usually presenting as severe contractures, which require complex, and often repeated, orthopaedic treatment. If untreated, foot deformities constitute an obstacle to achieving independent standing and/or functional walking and may become painful, fixed deformities causing difficulty with shoe fitting and other everyday care problems4-9. The general …

Application of systematic rehabilitation nursing procedure on improving the quality of life of patients with long-term conscious disturbance

Objective To investigate the application of systematic rehabilitation nursing procedure on improving the life quality of patients with long-term conscious disturbance. Methods A total of 7 patients with long-term conscious disturbance had been chosen as sampling and applied warm bath to stimulate, back slight vibration, sports training and other rehabilitation nursing program. The mild disturbance of consciousness re-scoring(NASVA ) was used to evaluate the quality of life improving in patients. Results The 7 patients received four stages rehabilitation nursing care (average 6 months) as its procedure, in which two patients got rid of decerebrate rigidity completely while five patients minimized the upper and lower extremity contractures of joint. Compared with the implementation of rehabilitation care before, the 7 cases of patients with long-term conscious disturbance improved their exercise, feeding, excretion, cognition, language expression, verbal commands and other aspects of NASVA score after rehabilitation care with statistically differences (P<0.01). Quality of life of 7 patients were significantly improved, of which one patients return to school to continue study, and four patients′ contractures of lower and upper extremity joint improved and they could go back home, and live with their family and eat by mouth. Conclusions Implementation of systematic rehabilitation nursing procedure can improve the rehabilitation effects for patients with long-term conscious disturbance and contributes to those patients′ quality of life. Key words: Quality of life; Long-term conscious disturbance; Systematic rehabilitation nursing procedure

P.11.6 Functional motor changes in Duchenne Muscular Dystrophy (DMD) patients on long term daily glucocorticoid (GC) treatment

Longitudinal review of motor outcomes for a cohort of DMD patients on GC would offer insight into the altered natural history of DMD, provide anticipatory guidance for care management and inform the study designs of future clinical trials. To report the motor outcomes of a cohort of DMD patients on long term daily GC. Longitudinal retrospective review of timed function tests (TFT) – Timed Gower maneuver (G) (i.e. sit to stand ¨C measure of pelvic girdle weakness), 10 m walk/run (W/R), North Star Ambulatory Assessment (NSAA); and lower extremity contractures. 110 males aged 7 to ⩽13 y were treated with daily GC for 4.8 ± 1.5 y and followed at our clinic for 4.8 ± 1.6 y. Slope changes were 9.0 y for G, 8.5 y for W/R and 8.5 y for NSAA. TFTs were highly correlated regardless of time point. Times for G and W / R were correlated at first ( r = 0.76) and most recent visit ( r = 0.83). Times for G and NSAA scores were correlated at first ( r = 0.76) and most recent visit ( r = 0.66). W / R times and NSAA scores were strongly correlated at first ( r = 0.82) and most recent visit ( r = 0.83). Knee contractures (KC) were not observed in ambulatory boys, but ankle contractures (AC) negatively impacted motor function as the disease progressed. Subjects with AC performed worse on all TFTs at most recent visit compared to those without AC. Linear regression analysis suggests motor function declines faster in subjects with AC compared to those without. Our slope changes for all three TFTs were >7 years (Mazzone, 2011). Given the strong correlation, the easily executed W / R test may be a clinical surrogate for NSAA in a busy clinic. Our results indicate that early intervention for AC may improve motor outcomes and prolong ambulation in DMD boys.

Systematic Review of Contracture Reduction in the Lower Extremity with Dynamic Splinting

IntroductionJoint contractures are relatively common disorders that can result in significant, long-term morbidity. Initial treatment is non-operative and often entails the use of mechanical modalities such as dynamic and static splints. Although widely utilized, there is a paucity of data that support the use of such measures. The purpose of this systematic review was to evaluate the safety and efficacy of dynamic splinting as it is used to treat joint contracture in lower extremities, and to determine if duration on total hours of stretching had an effect on outcomes.MethodsReviews of PubMed, Science Direct, Medline, AMED, and EMBASE websites were conducted to identify the term ‘contracture reduction’ in manuscripts published from January 2002 to January 2012. Publications selected for inclusion were controlled trials, cohort studies, or case series studies employing prolonged, passive stretching for lower extremity contracture reduction. A total of 354 abstracts were screened and eight studies (487 subjects) met the inclusion criteria. The primary outcome measure was change in active range of motion (AROM).ResultsThe mean aggregate change in AROM was 23.5º in the eight studies examined. Dynamic splinting with prolonged, passive stretching as home therapy treatment showed a significant direct, linear correlation between the total number of hours in stretching and restored AROM. No adverse events were reported.DiscussionDynamic splinting is a safe and efficacious treatment for lower extremity joint contractures. Joint specific stretching protocols accomplished greater durations of end-range stretching which may be considered to be responsible for connective tissue elongation.

Minimally Invasive Soft Tissue Release of Foot and Ankle Contracture Secondary to Stroke

Lower extremity contracture associated with stroke commonly results in a nonreducible, spastic equinovarus deformity of the foot and ankle. Rigid contracture deformity leads to gait instability, pain, bracing difficulties, and ulcerations. The classic surgical approach for stroke-related contracture of the foot and ankle has been combinations of tendon lengthening, tendon transfer, osteotomy, and joint fusion procedures. Recovery after traditional foot and ankle reconstructive surgery requires a period of non-weightbearing that is not typically practical for these patients. Little focus has been given in published studies on minimally invasive soft tissue release of contracture. We present the case of a 61-year-old female with an equinovarus foot contracture deformity secondary to stroke. The patient underwent Achilles tendon lengthening, posterior tibial tendon Z lengthening, and digital flexor tenotomy of each toe with immediate weightbearing in a walking boot, followed by transition to an ankle-foot orthosis. The surgical principles and technique tips are presented to demonstrate our minimally invasive approach to release of foot and ankle contracture secondary to stroke. The main goal of this approach is to improve foot and ankle alignment for ease of bracing, which, in turn, will improve gait, reduce the risk of falls, decrease pain, and avoid the development of pressure sores.

Combination of steroids and ischial weight-bearing knee ankle foot orthoses in Duchenne’s muscular dystrophy prolongs ambulation past 20 years of age – A case report

Patients with Duchenne muscular dystrophy (DMD) lose ambulation by age 12. Long-term steroids have lengthened ambulation by 2–5 years. Ischial weight-bearing knee ankle foot orthoses prolong ambulation for 2–3 years. We report the outcome of the ambulatory status of a patient with DMD treated with daily steroid therapy and orthoses. This male patient was diagnosed with DMD at age of 2. He has been treated with daily steroids since age 7 years. He lost the ability to arise from the floor and walk up steps at age 14 and lost ambulation by age 16. He was fitted with orthoses at age 16 following surgical correction of his lower extremity contractures and regained independent ambulation. At age 20, he was able to stand independently in his orthoses and take steps with moderate support. We conclude that a combination of daily steroids and orthoses prolongs ambulation beyond that of the natural history DMD.

Surgical Treatment of Pressure Ulcers of the Heel in Skilled Nursing Facilities

Chronic nonhealing pressure ulcers of the heel in nursing homes are frequent occurrences among bedridden patients with lower-extremity contractures of varying degrees of severity. Conservative local wound care for these patients can be time consuming, ineffective, costly, and may only delay an eventual major leg amputation. This study evaluates the efficacy of limb salvage surgical procedures, partial calcanectomy, total calcanectomy, and excision of the entire calcaneus and talus, for heel ulcers. We performed a retrospective review of 57 nursing home residents who had chronic infected nonhealing pressure ulcers of the heel that we had treated over 12 years. Forty-three patients underwent partial calcanectomy, nine underwent total calcanectomy, and five underwent excision of the entire calcaneus and talus. Average postoperative follow-up was 15 months. Also included in this study are representative surgical cases. Forty-three patients completed follow-up. Complete healing occurred in 25 patients (58%). Failure to resolve the heel ulcer owing to persistent infection, or recurrence was seen in 18 patients (42%) who eventually had a below-the-knee or above-the-knee amputation. All of the patients with heel pressure ulcers were found to have lower-extremity contractures. In the nonambulatory contracted patient with a heel ulcer, partial or total calcanectomy or excision of the entire calcaneus and talus offer a viable alternative not only for resolution of infection but also for prevention of limb loss. An aggressive plan must also be instituted to address the lower-extremity contractures in order to prevent recurrence.

Case Study: Asphyxia Caused by Inspissated Oral and Nasopharyngeal Secretions

Case Study: Asphyxia Caused by Inspissated Oral and Nasopharyngeal Secretions

Tethered cord release: a long-term study in 114 patients

All children born with a myelomeningocele at the authors' institution undergo aggressive treatment to maintain or improve functional outcome. Consequently, when any neurological, orthopedic, and/or urological changes are noted, a search for the cause is initiated. The most common cause of decline in a child born with a myelomeningocele is shunt malfunction. The second most common cause is tethering of the distal spinal cord at the site of the original back closure. In this report, the authors review the indicators of symptomatic spinal cord tethering and discuss the surgical interventions and outcomes in the children with myelomeningocele who underwent treatment at Children's Memorial Hospital from 1975 to 2008. Among the 502 children who underwent original closure at Children's Memorial Hospital, a symptomatic tethered spinal cord developed in 114 (23%). Eighty-one patients (71%) have undergone 1 untethering procedure, and 33 patients (29%) have undergone multiple untetherings, for a total of 163 total surgeries. The indicators of symptomatic spinal cord tethering include scoliosis, decline in lower-extremity (LE) motor strength, LE contractures, LE spasticity, gait change, urinary changes, and pain. Pain has shown the best response to surgical untethering, with 100% of children experiencing postoperative improvement. The results of long-term follow-up (average 12 years, range 1 month-23.3 years) in this cohort demonstrated scoliosis progression after surgical untethering in 52% of patients, with 28% requiring spinal fusion. On the 3-month postoperative manual muscle test, 70% of patients showed improved LE muscle strength compared to preoperatively. Gait was also similarly improved after untethering as evaluated by an orthopedic surgeon. Spasticity improved in two-thirds of the cohort, and as expected, LE contractures were stable (78%) postoperatively, as assessed by orthopedic and rehabilitation medicine specialists. Urologically, 64% of patients showed improvements on postoperative bladder evaluation. Although this is a clinical outcome study with no control group, the authors' experience has been that tethered cord release is beneficial in maintaining neurological, urological, and orthopedic functioning in children born with a myelomeningocele.

Are Reverse Flow Fasciocutaneous Flaps an Appropriate Option for the Reconstruction of Severe Postburn Lower Extremity Contractures?

Full thickness burns involving the lower extremity can result in severe contractures, which impair extremity functions if they are not managed with proper treatment and rehabilitation. After release of postburn contracture of the knee, ankle, and metatarsophalangeal joints, defects often require coverage by flaps. Twelve distally based reverse flow flaps were performed for lower-extremity reconstruction after release of postburn flexion contractures. All of the patients were male and their age ranged from 20 to 23 years, with a mean age of 21. After the release of the contractures, 3 flaps were used based on the location of the contractures. The reverse flow anterolateral thigh flap was used for knee reconstruction (n = 4, 33%). The reverse flow sural flap was used for ankle reconstruction (n = 4, 33%), and the reverse flow medial plantar flap was used for metatarsophalangeal reconstruction (n = 4, 33%). The sizes of the flap varied from 2 to 17 cm wide and 3 to 18 cm in length. All defects were covered successfully. Reverse fasciocutaneous tissue transfer to reconstruct the soft tissue defects provide early motion. Sufficient contracture release is achieved without displacement of anatomic landmarks. The reverse-flow flap is a reasonable and reliable choice for each joint level in the lower extremity.

Knee Disarticulation and Hip Release for Severe Lower Extremity Contractures

Severe lower extremity contractures cause many problems for patients and their caregivers. Hygiene, skin and perineal care, positioning, and dressing are severely compromised. Surgical management of such deformities is challenging and results have not been published. We treated eight nonambulatory adults with severe and rigid lower extremity contractures with hip release and knee disarticulation of 14 extremities. The patients had neurologic disorders with spasticity. The indications for surgery were fixed contractures of at least 90 degrees at the knee and hip that interfered with passive function and quality of life. All patients were bed-bound secondary to their contractures. The average age at surgery was 57 years; the minimum followup was 6 months (mean, 34 months; range, 6-102 months). The average preoperative flexion contractures were 106 degrees at the hips and 139 degrees at the knees. The average postoperative hip flexion contracture was 6 degrees , and there were no serious complications or recurrent contractures. Positioning and hygiene problems were universally improved, enabling all of the patients to become wheel-chair users, and all patients or their caretakers reported resolution of pain.