Kirby Noonan Lance & Hoge, LLP

By Q. Xardas. Clayton College and State University.

Knee Operative Procedures 977 proximal fragment sometimes is much less than the circumference of the distal fragment discount zithromax 100 mg visa antimicrobial qt prolongation. The reduction should be performed in the mid- line with the anterior cortices aligned order zithromax 100 mg online antibiotic resistance in the us. Then, the osteotomy is com- pressed, using the compression holes and the side plate. The removed bone then can be fragmented and placed alongside the osteotomy to fill in the major defects (Figure S4. Advancement of the patellar ligaments usually is required because of the significant shortening that has occurred due to correction of major flexion contractures. If the growth plate of the proximal tibia is closed, the patellar ligament insertion on the tibial tubercle can be advanced by utilizing an osteotomy and resecting the tibial tubercle. The incision has to be extended distally, and this bone block ad- vanced distally to the point where 90° of knee flexion is allowed. The bone is roughened and a screw with a washer is inserted to hold the bone block with the inserted patellar ligament (Figure S4. If the tibial epiphysis is open, the use of patellar ligament plication is another alternative, and can be used for adults as well. This plica- tion is performed by obliquely transecting the patellar ligament and then overlapping it and suturing the ligament with heavy absorbable sutures so its length is such that the knee can just barely flex to 90° (Figure S4. The wounds are closed, being careful to perform a good closure of the lateral capsule. Postoperative Care For the child with good stable fixation by patellar advancement and good bony fixation, the knee is immobilized in a knee immobilizer only. For children who have had patellar ligament plication, or whose bones are less strong, the knee is immobilized in a knee cylinder cast. The knee cast may be split and used as a bivalve cast, which can be removed typically between 2 to 4 weeks, and gentle passive range-of-motion exercises begun. Weight bearing is allowed either immediately postoperatively if the fixation is suffi- ciently stable, or started at 4 to 6 weeks postoperatively. Knee extension splinting is required usually for 6 months, especially at nighttime to prevent recurrent deformity. Ankle Epiphysiodesis Screw Indication This procedure is used to provide a temporary unilateral epiphysiodesis to treat ankle valgus in a child with enough growth remaining for the valgus to correct. The procedure is done under fluoroscopic control introducing a guidewire through the superficial tip of the medial malleolus with the goal of the screw entering the epiphysis at its medial border. Then, the pin is introduced across the epiphyseal plate 5 mm from the medial edge of the epiphysis. The screw length should be long enough to contact the contralateral cortex, or should provide good fixation in the metaphyseal bone. The screw is countersunk slightly into the medial malleolus so it is not superficially prominent (Figure S5. Postoperative Care Postoperative care requires no immobilization for this procedure. Careful postoperative monitoring with radiographs is required every 4 to 6 months, and the screw should be removed as soon as full correction to very mild over- correction has been achieved. Subtalar Fusion Indication Subtalar fusion is indicated to treat planovalgus foot deformities in children with hypotonia or severe planovalgus collapse, especially in individuals who are marginal ambulators. Because subtalar fusion may cause some growth de- crease in the hindfoot, the procedure should not be used on very young feet. Age 5 to 7 years is the typical age when this procedure is first considered. The incision is made just anterior to the peroneus brevis tendon and then curved proximally to the anterior border of the lateral malleolus. Distally, the incision is extended and curved slightly toward the plan- tar surface at the base of the fifth metatarsal if needed (Figure S5.

Anterior transfer of the long toe flexors has been advocated as a way of balancing the foot with spastic varus cheap zithromax 250 mg with mastercard antibiotics qatar. This boy with severe diplegia had a complete transfer of the tibialis poste- rior through the interosseous membrane to correct equinovarus at age 13 years buy zithromax 500 mg free shipping antimicrobial body soap. By age 17 years, he had developed such severe foot and toe deformities that he could no longer walk (A). The feet developed severe supina- tion with claw toes (B). This procedure causes the worst deformed feet seen as a complica- tion of surgery. Complete anterior transfer of the tibialis posterior is rarely indicated in spastic feet. B Complications of Treatment Complications of varus foot deformity treatment are recurrent deformity and overcorrection. A mild valgus foot deformity is better tolerated than a mild varus foot deformity; therefore, the goal of treatment should be to get mild overcorrection. It is also important to recognize that the valgus attrac- tor is stronger in ambulatory diplegia than the varus attractor; therefore, over- correction in this population has to be done with extreme caution, especially in younger children. The most commonly reported complication from tendon surgery to cor- rect varus deformity is recurrent deformity, which is usually identified as a failure to correct the initial deformity completely, most often due to un- recognized hindfoot stiffness. Some of these children initially have a satisfactory result, but then are slowly drawn back toward the varus attractor as the varus gets worse with growth. The treat- ment of recurrent deformity usually requires a calcaneal osteotomy or a cal- caneocuboid joint resection and fusion. Another attempt at foot balancing may need to be performed with the osteotomy, including a split tibialis 742 Cerebral Palsy Management anterior transfer or lengthening of the residual tibialis posterior. A second split transfer is technically difficult to perform and not recommended be- cause of the significant scar that is present from the initial procedure. This scarring makes splitting of the tendon longitudinally very difficult and runs a high risk of developing tendon ruptures. Other causes of recurrent defor- mity, such as a tear of the transferred tendon, undoubtedly occur but are very difficult to diagnose. In exploration of one such case, the tendon end was very hard to identify apart from the scar tissue. Overcorrection is probably the most common complication, but it is largely missed or not perceived as significant. For many children, there is overcorrection into mild to moderate planovalgus; however, no complaints or clinical symptoms occur. Our experience has been that there are at least as many overcorrections needing surgery as there are recurrent deformities with long-term follow-up. The recurrent deformities occur more quickly and the overcorrections tend to come later, sometimes up to 10 years later, which is probably another reason why many short-term follow-up studies miss the overcorrections. Overcorrection into planovalgus requires treatment using the planovalgus treatment algorithm. Planovalgus Planovalgus deformity is the most common foot deformity in all ages of chil- dren with diplegia and quadriplegia. The following description is based on our expe- rience; however, there is a definite need for well-defined investigations in this area. Etiology The direct cause of planovalgus is multifactorial and includes muscle imbal- ance, abnormal forces, bony malalignment, genetic predisposition, and liga- mentous structure response. In most children, it is impossible to assess each factor in a way that is helpful to predict the outcome. The best way to pre- dict the outcome of the foot is to recognize that planovalgus is a very strong attractor, especially in ambulatory diplegia and in some quadriplegia. Mus- cle imbalance is much less clearly a major contributor to the etiology than it is in the development of equinovarus deformity. There have been reports of peroneal muscle EMG in children with CP in which no activity during stance phase is found. These spastic and overactive peroneal muscles are most common in nonambulatory children with quadriplegia but are occasionally recognized in ambulatory children. An abnormal force environment is the major factor in ambulatory children. This abnormal force comes from the stiffness caused by spasticity, in which the knee and ankle do not work as shock absorbers.

Blurred vision is another common side effect with anticholinergics order zithromax 250mg mastercard antibiotics for uti no alcohol. This symptom is often attributed to relatively reduced accommodation due to parasympathetic blockade and excessive dryness of the cornea buy 250 mg zithromax free shipping virus january 2014. For persistent symptoms, consultation with an ophthalmologist may be appropriate. Rarely, anticholinergic therapy can precipitate narrow angle Copyright 2003 by Marcel Dekker, Inc. The acute increase in intraocular pressure presents with pain and redness in the affected eye. Risk of narrow angle glaucoma is minimal if there are normal pupillary responses and intact vision. Ophthalmology consultation should be sought during anticholinergic treatment should vision diminish or pupillary responses become abnormal. In contrast, the more common open angle glaucoma presents minimal risk for treatment with anticholinergics (54). Careful consideration of risk-benefit analysis is needed when prescribing anticholinergic medications. Patients should be counseled about the potential for side effects and instructed to call with any problems. In younger patients without comorbidity besides mild PD, anticholinergics are generally very well tolerated and represent a viable option for tremor- predominant symptoms. In more susceptible patients with clinically relevant autonomic dysfunction, cognitive dysfunction or advanced age, anti- cholinergics should be used very sparingly. Mechanisms of Action Antiparkinsonian benefit is generally attributed to inhibition of central muscarinic acetylcholine receptors. For instance, Duvoisin and Katz (55) reported an antiparkinsonian benefit to benztropine and scopolamine, both centrally acting anticholinergics, with an exacerbation of parkinsonism after a trial of physostigmine, a centrally acting anticholinesterase. In contrast, peripheral anticholinergics (methyl scopolamine and propantheline) and a peripheral anticholinesterase (edrophonium) did not affect parkinsonian symptoms (55). Details of how centrally acting anticholinergics can modify PD symptoms, usually attributed to dopaminergic deficiency, remain unclear. Abnormalities in the central acetylcholine neurotransmitter system have been described in PD patients (67,68). An oversimplified but clinically useful conceptualization is that the anticholinergic use corrects an imbalance between dopamine and acetylcholine (69). The depleted nigro-striatal dopaminergic system in PD causes a relative increase in striatal acetylcho- line-dopamine ratio, which can be normalized by use of anticholinergics. Other miscellaneous proposed mechanisms include inhibition of dopamine reuptake (70) and mild NMDA glutamate antagonism (71). The clinical significance of these findings remains to be determined. Summary Anticholinergics have relatively few clinical uses in PD other than the treatment of tremor in young-onset patients. Anticholinergics can be used in younger patients with problematic PD-associated dystonia unresponsive to or intolerant of dopaminergic manipulation. Secondary anticholinergic effects may occasionally be helpful for insomnia, sialorrhea, or urinary frequency. Appropriate caution remains in judging risks of side effects versus benefits in anticholinergic use, particularly in patients who may be more susceptible to either the central or peripheral anticholinergic effects. SUMMARY With the advent of specific dopaminergic agents, the roles of amantadine and anticholinergics have taken a back seat. Traditional uses still dominate with amantadine used as a mild antiparkinsonian agent with a well-tolerated side effect profile and anticholinergics used to treat tremor predominant PD. In addition, evidence that amantadine has efficacy in the modulation of later stage PD motor complications is clinically helpful information. Careful judgment of use of both of these agents related to their respective side effect profiles remains a concern, particularly with anticholinergics in susceptible elderly patients.