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    Correction of angular deformities of the knee by percutaneous hemiepiphysiodesis
    (Lippincott Williams & Wilkins, 2007) Inan, Muharrem; Chan, Gilbert; Bowen, J. Richard
    Predicting patients' remaining angular growth and timing for hemiepiphysiodesis are crucial for correcting coronal plane knee deformities in children. We asked whether the Angular Deformity Versus Growth Remaining Chart predicted correction of coronal angular deformities of the knee in children. Serial orthoroentgenograms and the predictive chart were used to time percutaneous hemiepiphysiodesis, and the children were followed until skeletal maturity. Twenty-rive consecutive children (35 extremities) with a mean skeletal age of 13 years (range, 9.6-16 years) had percutaneous hemiepiphysiodeses as described by Bowen and Johnson, and were followed up until skeletal maturity. At skeletal maturity, correction of varus and valgus coronal plane deformities were within 2 degrees (range, 0 degrees-6 degrees) of the predicted value. The maximum limb-length discrepancy resulting from the procedure was 1.5 cm. The only complication was failure of a physeal bar formation hemiepiphysiodesis; this was treated successfully with a repeat percutaneous hemiepiphysiodesis. The percutaneous hemiepiphysiodesis is effective and has a low complication rate. Angular correction and timing for hemiepiphysiodesis can be predicted by using the Angular Deformity Versus Growth Remaining Chart in children with coronal plain knee deformities.
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    Epiphysiodesis in a patient with osteopetrosis
    (Lippincott Williams & Wilkins, 2006) Inan, Muharrem; Chan, Gilbert; Bowen, J. Richard
    We describe a 14-year-old girl with intermediate-type osteopetrosis who presented with a 4.8-cm leg-length discrepancy secondary to premature distal femoral growth plate closure. She had a projected leg-length discrepancy of 7 cm at maturity, which was predicted using Moseley charts. The patient was treated successfully with an epiphysiodesis. Her remaining growth was predicted by Moseley charts. A percutaneous epiphysiodesis can treat leg-length discrepancies in patients with osteopetrosis.
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    Heterotopic ossification following hip osteotomies in cerebral palsy: Incidence and risk factors
    (Lippincott Williams & Wilkins, 2006) Inan, Muharrem; Chan, Gilbert; Dabney, Kirk; Miller, Freeman
    The aims Of this Study are, first, to determine the incidence of heterotopic ossification (HO) in patients with cerebral palsy (CP) who have undergone pelvic and/or proximal femoral osteotomies and, second, to identify any risk factors that may, contribute to its development in this patient population. The radiographs of 219 consecutive patients with CP who underwent proximal femoral osteotomies with or without pelvic osteotomies were reviewed. Risk factors including gender, age, and degree of involvement, ambulatory status, previous hip operations, bilateral hip surgery, capsular release, concomitant pelvic osteotomy. infection, and history of exuberant callus were evaluated. Thirty-five (16%) patients were diagnosed with HO and the 5 factors that cause HO were identified, which are degree of involvement (quadriplegic), ambulatory status, capsular release, infection, and previous hip operations. Based on logistic regression analysis. if a patient had quadriplegic type of CP, then they have 17.5 times more risk for HO than a patient with hemiplegic type, and capsular release increases the risk 237 times. Although HO Occurred in 16% of patients treated with bony procedures in the hip, in a small group (2%) of children it had a clinically significant limitation requiring surgical resection. In this Study, clear risk factors were presented for the development of HO; however, none of these risk factors can be altered in ways that will reduce the risk for HO. These risk factors might be used to define a high-risk group in whom attempts at prophylactic treatment lot, prevention of HO Could be initiated.
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    Knee arthritis in congenital short femur after Wagner lengthening
    (Springer, 2006) Jeong, Changhoon; Inan, Muharrem; Riddle, Eric C.; Gabos, Peter G.; Bowen, J. Richard
    Knee anomalies are common in patients with congenital short femurs who require lengthening to correct limb-length discrepancies. We retrospectively reviewed the incidence of knee arthritis and the factors influencing its occurrence after femoral lengthening using the Wagner method. Twenty-three patients with congenital short femurs treated with the Wagner method were followed up until skeletal maturity (minimum, 5 years postoperatively). The mean age of the patients at lengthening was 10.8 years (range, 8.4-14.5 years). The mean leg-length discrepancy at the time of surgery was 9.7 cm (femur, 7.6 +/- 3.7 cm; tibia, 2.1 +/- 1.8 cm). Femoral lengthening (mean, 7.9 cm) was performed in 17 patients. Femoral lengthening and tibial lengthening were performed simultaneously in six patents (mean, 11.8 cm). The mean age of the patients at the last followup was 16.8 years (range, 14-20.3 years). Eighteen patients had arthritis at followup. Nine patients had severe arthritis develop, seven of whom had knee instability preoperatively and temporary subluxation during the lengthening procedure. Seventy-eight percent of patients had arthritis develop in the knee after lower-limb lengthening using the Wagner method for congenital short femurs. Patients who had an unstable knee before surgery had temporary knee subluxation develop during the lengthening procedure, and patients who had simultaneous lengthening of the femur and tibia had a high association with degenerative arthritis changes in the knee.
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    Pectoralis major release to improve shoulder abduction in children with cerebral palsy
    (Lippincott Williams & Wilkins, 2007) Domzalski, Marcin; Inan, Muharrem; Littleton, Aaron G.; Miller, Freeman
    The aim of our study was to evaluate the surgical results after pectoralis major muscle release in children with cerebral palsy and to assess a caregiver's satisfaction in patient's care after this procedure. Twenty-one shoulders in 13 patients were analyzed at least 12 months after surgery. All but 1 patient involved in our study had quadriplegic type of cerebral palsy involvement. In 17 limbs, only pectoralis release was performed; in 4 limbs, latissimus dorsi release was added. After clinical examination, a questionnaire was used to determine the caregiver's assessment. The passive range of abduction and flexion was maintained at an angle greater than 90 degrees in 10 patients. External rotation was restricted in 6 patients. All caregivers would recommend this surgery to another patient. All but one reported improvement in care of the patients after surgery. The indication for this surgical procedure is limited only to the selected cerebral palsy cases in which custodial care is impaired by shoulder adduction contracture. The 2 main indications for the procedure are the limitations in the ability to bathe the axilla and the difficulty in dressing.
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    The proximal femoral growth plate in Perthes disease
    (Lippincott Williams & Wilkins, 2007) Domzalski, Marcin E.; Inan, Muharrem; Guille, James T.; Glutting, Joseph; Kumar, S. Jay
    We hypothesized the extent of involvement of the proximal femoral growth plate in Perthes disease determined the final radiographic outcome after containment by shelf acetabuloplasty. We retrospectively evaluated the extent of growth plate involvement using a modified version of the method described by Yasuda and Tamura. In our modification, we used only the epiphyseal border for measurements, which was clearly visible as a thin white line, unlike Yasuda and Tamura who used the metaphyseal and epiphyseal borders. We could not clearly demarcate the metaphyseal border in the radiographs of our patient population between 1944 and 1998, which consisted of 69 patients who had surgery at a mean age of 9 years (range, 6.0-14.1 years). From these measurements, we formulated an index termed growth plate involvement. Radiographic results were classified as described by Stulberg et al A growth plate involvement index less than 0.25 resulted in a good radiographic outcome. We found 93.2% sensitivity and 100% specificity in predicting Stulberg's outcomes. The growth plate involvement index is a reliable and reproducible measurement method and may be used prospectively as a useful prognostic factor to predict radiographic outcomes after containment acetabuloplasty. Level of Evidence: Level 11, prognostic study (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.
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    Unilateral versus bilateral peri-ilial pelvic osteotomies combined with proximal femoral osteotomies in children with cerebral palsy: Perioperative complications
    (Lippincott Williams & Wilkins, 2006) Inan, Muharrem; Senaran, Hakan; Domzalski, Marcin; Littleton, Arron; Dabney, Kirk; Miller, Freeman
    The purpose of this study is to evaluate if bilateral peri-ilial pelvic osteotomies (PIPO) combined with proximal femoral varus derotation osteotomies (VDRO) influenced postoperative complications in children with spastic quadriplegia. Bilateral and unilateral hip subluxation or dislocation secondary to spasticity was present in 29 and 61 patients, respectively. The children were divided into 2 groups: group I were to be performed a surgery for unilateral PIPO associated with bilateral VDRO, and group 2 were to be performed a surgery for bilateral PIPO and VDRO. The average age of patients at initiation Of Surgery was 11.7 years (range 5-20 years) for group 1 and 10.7 years (range, 5-19 years) for group 2. The hospital stay was similar for group 1 and 2 (P = 0.797), which was 9 days. In group 1, 11 (18%) of 61 children needed an average of 2 days (range, 1-7 days) in the intensive care unit postoperatively, and 4 of these 11 patients were reintubated because of respiratory problems. In group 2, 6 (20%) of 29 children were transferred to the intensive care unit postoperatively for all average of 2 days (range, 1-4 days) and 3 of these 6 children were reintubated because Of respiratory problems. In conclusion, respiratory problems and anemia were the most common early postoperative complications. which occur with a similar rate in children with spastic quadriplegia who underwent bilateral or unilateral peri-ilial pelvic osteotomy(ies) combined with proximal femoral osteotomies. We believe that bilateral hip procedures including PIPO, proximal femoral osteotomies, and soft-tissue release call be performed safely in I stage and, based on this data, the staged procedure would probably have the same risk as the first procedure.