The halo-Milwaukee brace. Case series of a revived technique

STUDY DESIGN: A case series in which the halo-Milwaukee brace was used for postoperative immobilization in children with complex congenital and developmental spinal deformities. OBJECTIVES: To describe the use of halo-Milwaukee orthosis in a pediatric population for stabilization of the cervical and upper thoracic spine. SUMMARY AND BACKGROUND DATA: Postoperative immobilization of the neck and upper thorax can be achieved with cervical orthoses, cervicothoracic lumbar orthosis, halo cast, Minerva jacket, or halo vest. In the young child or in individuals with severe deformities, prefabricated braces often do not provide adequate stability or predictable fit. The halo-Milwaukee brace has proven to be an effective and versatile technique in the management of complex pediatric spinal deformities. METHODS: Halo-Milwaukee brace immobilization was used in 12 patients after surgical stabilization of the upper thoracic or cervical spine. Technique and indications are discussed in this report. Surgical outcomes and complications were reviewed retrospectively in all cases. RESULTS: Application of the halo-Milwaukee brace was a clinically effective and safe means of controlling the upper thoracic and cervical spine. The orthosis was well tolerated and allowed access to the posterior incision. The brace is easily converted to a standard Milwaukee brace with neck ring. The pelvic segment of the brace is molded before surgery, and in most instances did not require postoperative modification. CONCLUSION: The halo-Milwaukee brace is a simple and convenient method of intraoperative and postoperative immobilization. The technique is applicable in patients who cannot be treated with more conventional off-the-shelf orthoses. The brace was well tolerated and allowed for early patient mobilization.     

The Luque trolley revisited. Review of nine cases requiring revision.

This study is a retrospective review of nine patients who underwent Luque instrumentation without fusion from 1982-1984. Average age at surgery was 9 years. Average preoperative curve was 51 degrees (30 degrees-70 degrees). All nine patients have had at least one revision. All of the revisions were technically difficult secondary to extensive fibrosis and weakened laminar bone. Spontaneous fusion was documented in all nine patients, limiting further correction. Final follow-up curves averaged 51 degrees (25 degrees-90 degrees). Average gain in spinal height was 5.8 cm (2.3 in) but only a small portion was derived from the instrumented levels. Segmental spinal instrumentation without fusion in immature patients was not effective in control of spinal deformity, nor did it allow anticipated growth under the instrumented regions.     

Regional fasciocutaneous flap closure for clubfoot surgery

Skin closure after a comprehensive posteromediallateral release of clubfeet through a Cincinnati incision may be difficult. This is especially true for cases of severe deformity either primary or recurrent. To deal with this, certain techniques have been developed. These consist of casting the foot in an undercorrected position with subsequent serial cast changes, leaving the incision completely or partially open for closure by secondary intention, using tissue expanders, and using different flap techniques. Five patients with nine clubfoot deformities who were treated with a comprehensive posteromedial-lateral release through a Cincinnati incision and underwent fasciocutaneous flap closure since June 1998 were included in this study. These flaps allowed correction and complete wound closure at the end of surgery without any skin tension. These flaps were constructed either in a rotational or V-Y advancement manner. None of the patients had any major complications. In summary, this new fasciocutaneous flap is a simple and reliable method in cases with primary skin-closure difficulties. It does not require special equipment or a plastic surgeon.     

Pseudoaneurysm after foot surgery

Pseudoaneurysm (PA) is recognized as a rare complication after pediatric foot surgery. We identified the incidence, pertinent clinical features, and response to surgical intervention in PA as a complication of foot surgery. Four PAs were identified after 2,756 foot operations, an overall incidence of 0.14%. These patients typically had symptoms between 2 and 3 months after index operation with an enlarging, pulsatile, compressible mass in the plantar medial aspect of the foot. Arteriography was helpful in planning surgical intervention. Operative treatment consisted of ligation and excision of PA in all patients. Final outcome of foot deformity surgery was not compromised.