Shriners Hospitals for Children - Twin Cities

Congenital clasped thumb is associated with deficient thumb extensor tendons. Reconstruction includes tendon transfer. Here, we describe a variant of the abductor pollicis longus (APL) tendon, not previously reported, contributing to the flexion deformity. The purpose of this study is to report examples of and offer surgical repair techniques for APL variants identified in patients with clasped thumb. We reviewed records of 11 consecutive patients undergoing reconstruction for clasped thumb. Surgical anatomy of the APL tendon was evaluated in all patients, followed by release of aberrant APL attachments. Participants were invited to return for an in-person assessment with a certified hand therapist. Data were collected regarding intraoperative findings, surgical techniques for reconstruction, postoperative thumb motion, and patient and caregiver satisfaction. Eleven children (12 thumbs) underwent aberrant APL release and rerouting between 2019 and 2021. Preoperatively, all thumbs were passively correctible to 0° of extension. In all patients, the APL was found to terminate palmar to the metacarpophalangeal (MCP) joint, creating an MCP flexion moment when tensioned. The average age at surgery was 7 years (range: 1-15 years), and the average follow-up was 14.2 months (range: 1-21 months). The mean postoperative thumb radial abduction was 55° (range: 20°-75°). When reconstructing clasped thumbs, surgeons should explore the presence of APL abnormalities. Release and centralization of the APL can improve thumb position and function. This technique may avoid the need for extra-anatomical tendon transfer in patients with clasped thumb.

Osteoporosis in individuals with severe kyphoscoliosis can decrease the likelihood of successful surgical fixation and cause substantial morbidity. Loosening of spinal fixation screws and spontaneous vertebral fracture at the fixation site have been reported in patients with severe osteoporosis following surgical fixation1-5. Spinal fixation surgery has gone through numerous changes in the past century, yielding better outcomes for patients. These advances include Harrington rods and hooks in the 1950s, sublaminal wires and anterior approaches in the 1970s, and, popularized by Cotrel et al., transpedicular fixation in the 1980s6-10. Since the 1990s, in order to obtain spinal fusion, there has been a trend to use pedicle screws that are more rigid than previous screws, allowing for greater curvature correction and higher fusion rates11. In addition, new therapies are now being investigated to aid in spinal fusion, including recombinant human bone morphogenetic protein, which stimulates new bone formation at the fusion site and eliminates the need for bone-grafting12,13. However, in patients with osteoporosis, spinal fixation surgery continues to be a challenge. One potential treatment that could be used to improve bone mineral density (BMD) in severe osteoporosis is teriparatide therapy. Teriparatide is the 34-amino acid N-terminal fragment of the parathyroid hormone molecule that can increase BMD, bone strength, and markers of bone turnover14. It is an anabolic drug that has been shown to increase rates of postoperative spinal fusion in rabbits15. Numerous studies show that postmenopausal women with osteoporosis who are treated with teriparatide have increased BMD and a substantial decrease in subsequent vertebral and hip fractures16-19. Teriparatide is particularly appealing for use perioperatively because of the concern for fracture-healing with bisphosphonate treatment20. A recent study showed that …

Treatment of congenital spine deformity has high surgical risk due to abnormal anatomy and dysmorphic pedicles. We hypothesized that an image-guided navigation system would result in a low rate of screw revision due to malposition. From 2007 to 2010, 142 screws were placed in 14 consecutive patients with congenital spine deformity using an intraoperative computer tomography (CT) (O-arm) and image-guided navigation system (Stealth). Mean age was 8.8 years (range, 1 to 18 y). Deformities included scoliosis (12), kyphosis (1), and spinal dysgenesis (1). Screws were placed from T2 to S1. An intraoperative CT verified screw position. Need for intraoperative screw revision is the primary outcome measure. Of the 142 screws placed, 1 required revision intraoperatively due to malposition (99.3% screw accuracy rate). The screw was at L3 and was successfully redirected. There were no complications due to screw malposition. This navigated congenital screw accuracy rate (99.3%) is higher than the 94.9% accuracy rate reported for non-navigated screws in all children undergoing pedicle screw fixation in a recent systematic literature review and higher than the reported 96.4% accuracy rate for navigated pedicle screws in children. Kosmopoulos and colleagues found a lower accuracy rate (86.6%) in adult non-navigated screws (P<0.0001) and adult navigated screws (93.7%). Of note, 9 pedicles were noted on navigation to be absent. Despite the goal of bilateral screw placement at each fusion level, 31 of 173 pedicles were left unfilled due to technical impossibility based on intraoperative CT imaging. This represents an 18% screw dropout rate. CT-guided navigation resulted in the successful placement of 142 pedicle screws in patients with congenital deformity and altered anatomy, which represents a 99.3% screw accuracy rate. This is comparable with the screw accuracy rate of 93.7% reported for adult navigated pedicle screws. Further, navigation prevented attempts of screw placement at levels with absent or impassable pedicles. Image-guided navigation and intraoperative CT are valuable tools for the safe placement of pedicle screws in patients with significant congenital spine deformity and altered anatomy. IV, Case Series.

Cerebral Palsy (CP) is a static disorder of movement and posture secondary to an insult to the developing central nervous system. The peripheral manifestations and functional impairments of this condition vary in severity from mild-to-profound. In hemiplegic CP, 1 side of the body is affected more than the other. Spastic hemiplegia is the most common type and that for which upper extremity surgery is most indicated. Treatment options range from physical therapy and splinting to botulinum toxin A injections (Botox) to tendon transfers to arthrodeses. This article will discuss the indications, preoperative evaluation, our preferred surgical technique, and postoperative protocol for the most commonly used tendon transfers in the upper extremity in spastic hemiplegia.

A retrospective radiographic review was performed on 41 patients with scoliosis associated with a Chiari I malformation and/or syringomyelia. To characterize curve patterns and curve features in this population and possibly refine the radiographic indications for magnetic resonance imaging in patients with a normal history and physical examination. A subset of patients with "idiopathic" scoliosis may have an underlying neurologic abnormality. The radiographic indications for magnetic resonance imaging in asymptomatic patients with a normal clinical examination are not well defined. Data were collected from standing posteroanterior and lateral radiographs. The curve pattern and specific curve features were recorded and compared with historic controls. Thoracic kyphosis and total lumbar lordosis were also measured. Fifty-one percent of patients were male. Ten curve patterns were identified, and, based on our criteria, approximately 50% of patients had an "atypical" pattern (left thoracic, double thoracic, triple, long right thoracic). A subset of those with "typical" patterns (right thoracic, right thoracic/left lumbar) had atypical features including a superior or inferior shift of the apex and/or the upper or lower end vertebrae. The mean kyphosis (T3-T12) was 41.8 degrees. Although the decision to obtain magnetic resonance imaging in a patient with scoliosis should be based on both clinical and radiographic criteria, we suggest that a heightened index of suspicion is warranted with certain curve patterns (left thoracic, double thoracic, triple, and a long right thoracic curve with end vertebra caudal to T12), and with a high or low apex and/or end vertebra, especially in males and patients with a normal to hyperkyphotic thoracic spine.

Summary: We describe our surgical technique of acute pediatric forearm lengthening and joint leveling for treatment of symptomatic forearm-length discrepancies. A retrospective clinical and radiographic analysis was performed of all patients undergoing acute forearm lengthenings of >1.0 cm between 1983 and 1993. Twenty-four acute forearm lengthenings were reviewed with an average follow-up of 3 years. The diagnosis included osteochondromatosis in 17 patients, growth arrest in four patients, and skeletal dysplasia in three patients. Surgical indications included progressive forearm or wrist deformity, significantly limited or painful forearm rotation, or radial-head subluxation. The average lengthening was 1.5 cm (range, 1.0-2.3), which was 9% of total length (range, 3-20%). The goal for lengthening and wrist-joint leveling was near-neutral ulnar variance and was achieved in all cases. We conclude that the forearm can be lengthened acutely successfully to achieve near-neutral ulnar variance in children with forearm-length discrepancies caused by osteochondromas, growth arrests, or bone dysplasias. The surgical technique and the results are described in 24 forearm lengthenings.

A randomized prospective study was undertaken to assess the role of fibular osteotomy in distal tibial derotational osteotomies. Thirty-five patients were randomized to "intact fibula" and "osteotomized fibula" groups. There were no statistically significant differences in the amount of intraoperative derotation, time to weight bear, time to healing, and the amount of correction retained at follow-up between the two groups. Complications in the intact fibula group included one delayed union and one recurrence. In the osteotomized fibula group, there were two cases of loss of fixation, two pin-tract infections, one delayed union of tibia, one pressure sore in the cast, one distal tibial physeal arrest, and one recurrence. Although the difference in the complication rate between the two groups did not reach statistical significance, our results suggest that in distal tibial derotational osteotomies, fixed with cross pins, it might be advantageous to leave the fibula intact.

The authors have developed a swing-shell closure with fourbar linkage that combines the advantages of the familiar bivalve with flexible overlap designs. Like the conventional hinged bivalve or “alligator-mouth” design, the swing shell has a rigid anterior panel that provides consistent weightbearing contours and positive vertical suspension. Like the flexible overlap system, the swing shell also offers ease of donning and accommodates volume changes. These advantages justify the added fabrication time, particularly when atrophy or growth is anticipated. Encouraging results in 24 of 25 orthotic cases led to the successful incorporation of the design into 15 prostheses for congenital anomalies.