Francesco Camara Blumetti

Artroscopia do quadril na epifisiólise grave

We present a case report of a 12-year-old boy diagnosed with slipped capital femoral epiphysis grade III, with an acuteon-chronic presentation, associated with severe functional impairment and significant reduction in hip range of motion. The patient underwent a Dunn-type trapezoidal wedge femoral neck subtraction osteotomy by hip arthroscopy, followed by closed reduction and fixation with a 6.5mm percutaneous screw. There was significant improvement of the clinical picture on the first postoperative day, allowing for early rehabilitation. After a brief review of the literature, the authors propose this novel surgical technique as a viable method to treat severe slipped capital femoral epiphysis, encouraging the development of new studies on the subject.

Avaliação da anatomia arterial no pé torto congênito através da ultrassonografia com doppler colorido

SUMMARY Objective: This investigation intended to evaluate anterior and posterior tibial arteries at the ankle joint level in congenital clubfoot, by using color Doppler ultrasound (CDU). Material and Method: Twenty patients with idiopathic clubfoot were selected, from which 18 had unilateral involvement and two had bilateral involvement. Of the 18 patients with unilateral clubfoot, 16 went through surgical treatment and the other two were submitted to conservative treatment with serial casting. Of the bilateral cases, one patient was treated surgically and the other was treated with serial casting. All patients were clinically and radiographi-cally assessed. We used the functional rating as described by Lehman. Then, CDU was applied bilaterally at the ankle joint level, trying to identify both posterior and anterior tibial arteries. Results: In our present series of 20 cases with idiopathic clubfoot, in just one patient we could not identify the anterior tibial artery at the ankle joint level. In 12 patients who have had their arterial flow speeds and diameters measured by UDC, a positive correlation was found between functional level and anterior tibial artery diameter. No statistically significant differences were found between both flow speed and diameter of anterior tibial artery of the normal side, when compared to the affected side (in patients with unilateral disease). Conclusion: In our sample, we could not find any significant differences in arterial morphology and flow speed between the normal and the affected side. Furthermore, we noticed that the better the clinical result of clubfoot correction, the larger the diameter of anterior tibial artery in affected feet.

Estudo da impressão plantar obtida durante o teste de Jack em crianças

Objective: To assess the plantar impressions obtained in children during the Jack test, with the aim of quantifying and analyzing their variability in the critical period for plantar foot arch formation. Method: A hundred and twenty feet from 60 healthy White children, recruited in an outpatient pediatric clinic, were examined. Our sample included 35 boys and 25 girls, ranging from 2 to 5 years. The Jack test was simulated using a 45o wedge-shaped orthosis applied to the hallux. Bilateral plantar impressions were acquired in the alternate single-foot standing position using a pedigraph. Two plantar impressions were obtained for each foot, with and without the orthosis. The exams were analyzed using the Valenti and Volpon methods. Statistical tests were applied. Results: In all cases, both the Valenti and Volpon indexes decreased as the orthosis was applied. Furthermore, the difference between both indexes with and without the orthosis decreased with age. Conclusions: It is possible to quantify the Jack test using plantar impressions with the Volpon and Valenti methods. The variability observed in plantar shape tended to decrease after 4 years of age. Finally, the Jack test gradually lost its capability to change plantar impression with age, which reduces its accuracy as a parameter for a good prognosis in longitudinal medial arch formation. Level of Evidence: Level IV, observational descriptive study.

Tratamento das fraturas da diáfise dos ossos do antebraço em crianças e adolescentes

Objective: The treatment and the angular deviations tolerated in diaphyseal forearm fractures in children evoke divergent opinions in literature. In view of this controversy, we idealized this study to evaluate the preferred treatment methods for this injury, during the 39th Brazilian Congress on Orthopedics and Traumatology. Methods: A total 759 questionnaires were answered (13% of total entrants). We addressed the general aspects of the study sample to obtain a profile of the orthopedic surgeons questioned. Results: Two clinical subjects were presented, aged 12 (CASE 1) and 5 years old (CASE 2), along with radiographs depicting forearm diaphyseal fractures of these patients. Data was gathered and submitted to statistical analysis. The overall preferred treatment in CASE 1 was closed reduction and fixation with Kirschner wires (26%), while in case 2 it was closed reduction followed by plaster cast (46%). Conclusion: Among orthopedic surgeons less than 30 years old, the choice for less invasive treatments and greater acceptance of angular values prevailed in both cases. The traumatologists accepted lower angular values and tended towards more invasive treatments, particularly for CASE 2. On the other hand, the pediatric orthopedic surgeon prefers less invasive treatments and accepts greater angular deviations.

Intra and interobserver concordance of the AO classification system for fractures of the long bones in the pediatric population

Objective The AO classification for fractures of the long bones in the pediatric population was developed and validated in 2006. However, the complexity of this system has limited its use in clinical practice and few studies in the literature have evaluated its reproducibility and applicability. The present study had the objective of determining the intra and interobserver agreement using the pediatric AO system, among physicians with different levels of experience. Methods After making the sample calculation, 108 consecutive radiographs on long-bone fractures in patients aged 0–16 years, coming from the digital files of the quaternary-level hospital, were selected. The radiographs were classified by five examiners with different levels of experience after prior explanations about the system. A chart containing images from the classification was made available for consultation. The evaluations were made at two different times by each observer. The Fleiss kappa index was used to ascertain the intra and interobserver agreement. Results Intraobserver agreement that was at least substantial was obtained for all the items of the classification and it reached excellent levels for all observers in relation to five of the seven items considered. The interobserver evaluation presented excellent levels of agreement in two items, substantial in two items, moderate to substantial in one item and poor to moderate in one item. No influence from the observers experience was observed with regard to obtaining higher or lower levels of agreement, either in the intraobserver or in the interobserver evaluation. Conclusions In this study, the intra and interobserver agreement was considered to be good or excellent for the pediatric AO classification system, for the parameters of bone, segment, paired bone, subsegment, standard and deviation. However, the intra and interobserver agreement was statistically unsatisfactory for the parameter of severity/side of avulsion. The levels of agreement obtained did not depend on the observers level of experience within pediatric orthopedics.

RADIOGRAPHIC ABNORMALITIES OF THE TALUS IN PATIENTS WITH CLUBFOOT AFTER SURGICAL RELEASE USING THE MCKAY TECHNIQUE.

Objective: To analyze morphological abnormalities of the talus in patients with clubfoot after surgical treatment using the McKay technique. Method: Lateral standing-position radiographs of the feet of 14 patients with unilateral clubfoot who underwent treatment by means of the doubleincision McKay technique were retrospectively analyzed. All the patients were operated by the same surgeon, with an average of 6.53 years between surgery and the radiograph. We compared the radiographic characteristics of the talus between the operated and the contralateral foot. We assessed the presence of deformity of the talar dome and head (sphericity evaluation); the talar length and height; the percentage and degree of navicular subluxation; abnormalities of the Gissane angle; and the trabecular bone pattern. Results: Abnormalities of the talar head occurred in 92.8% of the patients; of the talar dome in 92.8%; and of the trabecular pattern in 100%. The talar length ratio between the operated and the contralateral foot ranged from 0.61 to 0.88 (mean 0.79; SD = 0.09), while the height ratio ranged from 0.57 to 0.98 (mean 0.82; SD = 0.12). The Gissane angle was greater in all of the operated feet, and all of them also showed navicular subluxation, at a rate ranging from 6.43 to 59.75% (mean 26.34%; SD = 16.66%). Conclusion: Talar abnormalities occurred in 100% of the feet treated using the McKay technique. It was shown that establishing radiographic parameters to describe and quantify these deformities was feasible, through simple and easy-to-perform techniques.

Frouxidão ligamentar e pé plano em crianças normais

Objective: To study the correlation between flatfoot and joint laxity in healthy children. Methods: We evaluated 328 children with ages between 3 to 15 years, with no previous musculoskeletal complaints. We classified them by the presence of joint laxity according to the Beighton and Horan criteria, and by the presence of flatfoot according to the Valenti classification. The data obtained werecorrelated with gender, age, ethnic group, and dominant side. Fishers exact test and chi-square test were applied to analyze theresults. Results: A percentage of 83.9% ofindividuals with joint laxity was observed in children younger than 7 years of age (p < 0.001*). There is a significant association between joint laxity and gender (p = 0.025*), as girlsexhibited a greater percentage of laxity (51.02%). We observed a significant association between joint laxity and type of foot (p =0.003*), since the flatfooted group presented a higher percentage of laxity (54.96%). Flatfoot was also associated to joint laxity when we considered only the males (p = 0.001*), which was not observed in the females group. Conclusion: In the population studied, joint laxity was more frequently observed in children younger than 7 years of age, in females, and in individuals with flatfoot. There was no association between joint laxity and ethnic group or dominant side.

Correlação entre os índices de necrose e a estabilização precoce nas fraturas da extremidade proximal do fêmur na infância

OBJETIVO: Desenvolvemos este trabalho, com o intuito de avaliar o resultado do tratamento de pacientes portadores de fraturas do femur proximal, em uma serie de casos. Procuramos observar a influencia das complicacoes mais prevalentes nos resultados finais apos o minimo de dois anos de seguimento. Correlacionamos especialmente a instalacao da necrose avascular e o tempo entre o acidente e a instituicao da terapeutica. METODOS: Estudamos, retrospectivamente, 29 pacientes com fraturas da extremidade proximal do femur, com idade inferior a 14 anos entre 1988 e 2007. Analisamos as seguintes variaveis: sexo, idade, mecanismo de trauma, classificacao da fratura (Delbet), tratamento realizado, complicacoes (pseudartrose, deformidade em varo, anisomelia e necrose avascular), tempo para cirurgia e resultado (Ratliff). Obtivemos uma analise descritiva individual de cada variavel. Os testes foram utilizados de acordo com a adequacao das premissas de normalidade e para avaliacao utilizamos o teste exato de Fisher. RESULTADOS: Obtivemos cinco (17,2%) pacientes com necrose avascular sendo tres (60,0%) com idade superior a 10 anos; 73,3% dos pacientes tratados nas primeiras 24 horas apresentaram bons resultados; a causa mais comum de fratura foi acidente automobilistico (44,8%); os melhores resultados foram observados nos pacientes tratados cirurgicamente; 41,4% evoluiram com algum tipo de complicacao. CONCLUSOES: Entre os 29 pacientes tratados, segundo os criterios de Ratliff, obtivemos 58,6% de bons, 27,6% de regulares e 13,8% de maus resultados. Quando aplicado o tratamento incruento, obtivemos apenas 17,0% de bons resultados, enquanto que apos o tratamento cirurgico obtivemos 69,3%. Da mesma forma, observamos que houve 73,3% de bons resultados quando a cirurgia foi realizada nas primeiras 24 horas e apenas 42,8% nos pacientes submetidos a intervencao terapeutica apos este periodo. Pacientes submetidos a cirurgia nas primeiras 24 horas evoluiram com necrose da cabeca do femur em 13,3%, enquanto os que foram operados apos este periodo tiveram esta complicacao em 21,4% dos casos.

The increase of anterior pelvic tilt after crouch gait treatment in patients with cerebral palsy

BACKGROUND The increase of anterior pelvic tilt (APT) has been described after the treatment of crouch gait in cerebral palsy (CP). The ideal treatment option for flexed knee gait in CP should provide knee extension improvement in the stance phase without generating the increase of APT. RESEARCH QUESTION The purpose of this study was to compare three different approaches used for the treatment of crouch gait in CP [distal femur extension osteotomy (DFEO), patellar tendon shortening (PTS) and the combination of DFEO +PTS] regarding the increase of APT after the interventions. METHODS The inclusion criteria were: (1) diagnosis of spastic diplegic CP, (2) GMFCS levels I-III, (3) patients who underwent DFEO and/or PTS and (4) with complete documentation in the gait laboratory before and after the intervention. The included patients were divided into 3 groups, according to the procedures performed for crouch gait treatment: PTS (19 patients), DFEO (54 patients) and PTS + DFEO (22 patients). RESULTS During stance phase, knee flexion decreased from 41.60 to 13.60 in the PTS group (p < 0.001), from 46.00 to 30.70 in the DFEO group (p < 0.001) and from 52.30 to 29.50 in the PTS + DFEO group (p < 0.001). APT increased 140 (p < 0.001) in the PTS group, 7.1° (p < 0.001) in the DFEO group and 6.60 (p < 0.001) in the PTS + DFEO group after surgical intervention. The PTS group presented a more significant deterioration of pelvic tilt than the DFEO (p = 0.002) and PTS + DFEO (p = 0.001) groups. The increase of APT was higher when HSL was also performed in the PTS + DFEO group (p = 0.016). SIGNIFICANCE The increase of APT was observed in all studied groups, but it was more significant for those who underwent a PTS. The inclusion of HSL in the surgical plan was related a higher increase of APT in the PTS + DFEO group.

The effect of the Majestro-Frost procedure on internal hip rotation during gait in patients with cerebral palsy

BACKGROUND Muscle imbalance is related to persistent internal hip rotation (IHR) after femoral derotation osteotomy (FDO) in cerebral palsy (CP). The aim of this study was to evaluate the effect of the Majestro-Frost soft tissue procedure (MFP), which potentially addresses muscle imbalance, on IHR in CP patients during walking. METHODS A retrospective study of an existing database (medical records and gait laboratory data) was conducted and a search was performed using the following inclusion criteria: (1) diagnosis of spastic CP, (2) GMFCS levels I-III; (3) mean IHR during stance phase higher than 11° at baseline; (4) individuals who received single event multilevel orthopedic surgery in the lower limbs and had three-dimensional gait analyses (3DGA) before and after the intervention. Patients who underwent a FDO were excluded. Eighty-three individuals were considered for the study and they were divided into two groups: No MFP (45 patients who did not receive a MFP) and MFP (36 patients who underwent a MFP). A full clinical examination and 3DGA, with kinematics calculated according to a standard software procedure (Plugin Gait), were performed before and after the intervention, and the results were compared. RESULTS The studied groups matched regarding demographic data and GMFCS distribution. The mean follow-up time was more than 20 months on both groups. The increase of clinical external hip rotation (EHR) on physical examination was observed only in the MFP group (from 26.4° to 33°, p = 0.002). During gait analysis, IHR decreased from 21.2° to 4.5° in the MFP group (p < 0.001) and from 16.9° to 7.9° in the No MFP group (p < 0.001). The reduction of IHR during gait was more significant in the MFP group (p = 0.001). SIGNIFICANCE In the present study, patients who underwent a MFP showed more reduction of IHR during gait than those which did not undergo a MFP.