Gilberto Waisberg

Avaliação clínica, radiográfica e laboratorial de pacientes com osteogênese imperfeita

BACKGROUND: Osteogenesis imperfecta is a genetic disorder characterized by defects in type I collagen. The main symptom is bone fragility and susceptibility to fractures. Other clinical findings are dentinogenesis imperfecta, blue sclera, early deafness and joint laxity. The purpose of this paper is to establish a practical relationship of the clinical differences between the Sillences groups. METHODS: 22 patients were classified according to Sillence et al criteria and submitted to laboratory tests including blood calcium level and bone densitometry. RESULTS: All clinical and laboratory differences were discussed in the text. CONCLUSIONS: Differences such as results that were found in walking ability, height and bone densitometry were significant and may help to classify patients and to establish prognosis.

A operação de Sofield e Millar no tratamento da osteogênese imperfeita

SUMMARY Osteogenesis imperfecta is a genetic disease caused bydefects in the synthesis of type I collagen; clinical characteristicsare short stature, blue or gray sclera, skeletal deformities andbone fragility. We analyzed eight cases of osteogenesis imper-fecta with deformities and history of many fractures, for that theSofield and Millar surgery was performed in 23 bones. After amean follow up period of ten years and two months, 11 bonesdid not need revision, twelve bones had 21 complication thatneeded revision, ten by rod migration, six by refracture, three bynew deformities and two by nonunion. There were no cases ofinfection or neurovascular lesion. This surgery was able to cor-rect deformities, make fracture less frequent and prevent newdeformities; revisions were necessary three years and two mon-ths after the primary surgery. All patients maintained or improvedtheir ability to walk right after surgery; during the follow up, twopatients, in which the disease was more severe, had their walkingability decreased and are non ambulatory now.Keywords: Osteogenesis imperfecta; gait; osteotomy

Análise de fraturas diafisárias do fêmur em crianças menores de 3 anos de idade

This study consists of an orthopaedic and psychosocial re-evaluation of children who experienced femur fractures as young as 3 years old and aims to analyze potential causes and detect Child Abuse rates. Thirty-five children under the age of three years who experienced femoral shaft fractures received care at the Emergency Department of the Orthopaedics and Traumatology Service of Santa Casa de Sao Paulo within the period ranging from January, 1996 to August, 2002. Eighteen patients returned to the hospital for re-evaluation. The reported causes for fractures were: fall in 13 cases (72.2%), object fall on the limb in 2 cases (11.1%). Child abuse was suspected in 9 cases (physical abuse in 6 cases (33.3%), negligence in 3 cases (16.7%), pathological fracture in 4 cases (22.2%), accidental causes in 3 cases (16.7%), and other causes in 2 cases (11.1%). Child abuse constitutes an important cause that needs to be investigated in cases of femur fracture in children under the age of three years and this has possibly been the mechanism responsible for half of the fractures investigated in the current study.

Avaliação radiográfica na epifisiolise: possíveis preditores de bilateralidade?

Objective To identify anatomical changes and skeletal maturity through radiographic analysis, allowing more accuracy for indication of surgical management of non-slipped hips in patients with epiphysiolisys. Method A retrospective study of the radiographs of 61 patients followed until the end of skeletal growth, assigned to two groups: 37 patients with unilateral epiphysiolysis, and 24 patients with contralateral epiphysiolysis diagnosed during follow-up. The skeletal maturity was evaluated using pelvis radiographs (Oxford method) and compared between the groups for patients of the same gender. In addition, the Southwick angle (in anteroposterior and in Lauenstein view), physeal sloping angle and physeal posterior sloping angle were compared as well. Results Skeletal maturity showed a statistically significant difference between the two groups for both genders. It was observed that the lateral view of the Southwick angle is mathematically equal to the physeal posterior sloping angle, and were the only ones to show relevant differences between the groups. Conclusion The Oxford method and the Southwick angle in Lauenstein view can be utilized as parameters to help the physician to better indicate the prophylactic surgical treatment of the contralateral hip, in patients with slipped capital femoral epiphysis (SCFE). Level of Evidence III, Diagnostic Study.

Fraturas da diáfise da tíbia em crianças

As fraturas da diafise da tibia nas criancas e adolescentes sao lesoes relativamente comuns e geralmente tem boa evolucao com os metodos classicos de tratamento conservador. Sua elevada frequencia se deve ao alto grau de exposicao da crianca nas suas atividades fisicas e tambem pela anatomia e topografia da tibia, expondo-a ao trauma direto ou indireto. Algumas particularidades devem ser consideradas e respeitadas na sua abordagem, que compreendem aspectos atinentes a faixa etaria, local de acometimento (se proximal ou distal), tipo de fratura e de terapeutica instituida. A vantagem anatomica do periosteo mais espesso e a relativa flexibilidade na acomodacao de impactos angulares podem proporcionar na crianca de menor idade, maior estabilidade e consequente tendencia ao melhor prognostico. Nas criancas maiores e nos adolescentes o grau de exposicao a traumas de maior energia, a maior gravidade e complexidade das lesoes tem tornado mais comum a estabilizacao cirurgica. Complicacoes encontradas nessas fraturas nos adultos como infeccao, retarde de consolidacao e pseudartrose sao muito menos frequentes nas criancas, mas o risco de instalacao de sindromes compartimentais e uma eventualidade que requer atencao, principalmente nas condutas incruentas com imobilizacoes gessadas.Study conducted in the Pediatric Orthopedics Group of the Department of Orthopedics and Traumatology of the Central Hospital of Faculdade de Ciencias Medicas da Santa Casa de Sao Paulo, “Pavilhao Fernandinho Simonsen”. Director: Prof. Dr. Osmar Avanzi Mailing address: Departamento de Ortopedia e Traumatologia da Santa Casa de Misericordia de Sao Paulo Grupo de Ortopedia e Traumatologia Pediatrica do Hospital e da Faculdade de Ciencias Medicas da Santa Casa de Sao Paulo – Rua Cesario Motta Junior 112 CEP: 01277-900. Vila Buarque Sao Paulo-SP. Brazil. Site: www.ortopediatrica.com.br. E-mail: ortopediatrica@yahoo.com.br

Tratamento incruento das fraturas diafisárias do fêmur nas crianças

The purpose of this study is to analyze the progression of children presenting femoral diaphyseal fractures, conservatively treated, by evaluating clinical and radiographic complications, emotional changes and estimated costs for this kind of treatment. Thirty-two patients were evaluated, with ages ranging from 6 to 16 years old, receiving healthcare within the period of January 1995 and August 2001. In this group, six patients were females and 26 were males, with a mean age of 8 years and five months old. Sixteen patients were further evaluated, with an average follow-up time of 42.2 months. In those patients, ten angle deformities and nine lower limbs discrepancies were seen. During psychological evaluation, fifteen patients reported anxiety and restricted social life during treatment, and two patients lost school year. Eleven families reported difficulties in taking care of the child during the home-based phase of therapy. As for the analysis of costs, the treatment using traction followed by cast has shown to be 22.5% more expensive than surgery with flexible intramedullary nail. Although clinical outcomes were satisfactory, allowing a fast return to usual daily activities, the bloodless treatment has shown to be more expensive than other available approaches, and may potentially trigger emotional changes in children and their families.

Evolução do escorregamento epifisário proximal do fêrmur após tratamento não cirúrgico

OBJETIVO: Avaliar a eficacia do tratamento conservador em pacientes com epifisiolise proximal do femur (EEPF) e as complicacoes devidas a evolucao da doenca. METODOS: Foram analisados, retrospectivamente, 18 pacientes (26 quadris) consecutivamente atendidos no periodo entre dezembro de 1996 e agosto de 2006 no Servico de Ortopedia da Santa Casa de Misericordia de Sao Paulo, encaminhados por outros servicos com diagnostico de EEPF e tratados de forma nao cirurgica. RESULTADOS: A progressao do escorregamento aconteceu em 19 quadris (73%), sendo que, dos quadris com escorregamento leve, oito permaneceram leves, quatro progrediram para moderados e um tornou-se grave pela classificacao Southwick. Dos seis quadris classificados como moderados, quatro evoluiram para grave e os dois graves acentuaram-se um pouco mais. Conclusoes: Apesar de a indicacao cirurgica ser hoje consenso no tratamento do EEEP para evitar a progressao do escorregamento, ha ainda pacientes com diagnostico confirmado que sao tratados de forma conservadora, e isto representa um grande erro, pois implica no aumento da morbidade da doenca.

Limping in children

Limping in children is a common complaint at pediatric, pediatric orthopaedic offices and in emergency rooms. There are several causes for this condition, and identifying them is a challenge. The older the patient, the better the anamnesis and more detailed the physical examination will be, enabling an easier medical assessment for searching the source of the disorder. In order to make the approach easier, three age groups can and should be considered. Among infants (1 to 3 years old), diagnosis will most likely be: transitory synovitis, septic arthritis, neurological disorders (mild brain palsy (BP) and muscular dystrophy), congenital hip dislocation (CHD), varus thigh, juvenile rheumatoid arthritis (JRA) and neoplasias (osteoid osteoma, leukemia); in the scholar age group, between 4 and 10 years old, in addition to the diagnoses above, Legg-Calvé-Perthes disease, discoid meniscus, inferior limbs discrepancy and unspecific muscular pain; in adolescents (11 to 15 years old): slipped capital femoral epiphysis, congenital hip dislocation, chondrolysis, overuse syndromes, dissecans osteochondritis, and tarsal coalition. The purpose of this study is to provide an update on how to approach pediatric patients presenting with limping, and to discuss its potential causes.

EVOLUTION OF SLIPPED CAPITAL FEMORAL EPIPHYSIS AFTER NONSURGICAL TREATMENT

To evaluate the efficacy of conservative treatment of patients with slipped capital femoral epiphysis (SCFE) and the complications due to the progression of the disease. Methods: 18 patients (26 hips) seen consecutively from December 1996 to August 2006 at the Orthopedics Service of Santa Casa de Misericórdia de São Paulo, who had been referred from other services with a diagnosis of SCFE and were treated without surgery, were retrospectively analyzed. Results: Slip progression occurred in 19 hips (73%). Among the mild cases, eight remained mild, four became moderate and one became severe, according to the Southwick classification. Four out of the six originally moderate cases became severe and the two already severe cases worsened. Conclusion: Although today there is a consensus regarding the indication of surgical treatment for SCFE to prevent progression, some cases with confirmed diagnoses are still being treated conservatively. This is a major error, since it implies increased morbidity of the disease.

Coxa vara do desenvolvimento

OBJECTIVE: To evaluate the clinical and radiographic findings observed after surgical treatment of patients with developmental coxa vara (DCV) and review its epidemiology and natural history. METHOD: We selected 19 patients (26 hips) with DCVthat underwent subtrochanteric osteotomy with a mean follow-up period of four years and ten months and a minimum of 12 months of follow-up. We analyzed the range of motion of the hips, the Trendelenburg sign, and the discrepancy of the length of the lower limbs.In the radiographic evaluation, we measured the epiphyseal-diaphyseal (ED) angle and articulo-trochanteric distance (ATD) at different times. RESULTS: We observed an average increase of 21° in the amplitude of hip abduction, as well as the disappearance of theTrendelenburg sign. In assessing the length discrepancy, 72.2% of the 18 patients studied were equalized, witha residual difference of up to 0.5cm between the limbs. The rangeof the ATD showed an average of -0.34 cm in the preoperative period, 2.18 cm in the immediate postoperative period, and 1.35 cm in the last evaluation.The ED angle had an average valueof 91° preoperatively, 142° in the immediate postoperative period, and 133° in the last evaluation. CONCLUSION: The subtrochanteric valgus osteotomy, leading to epiphyseal-diaphyseal angles close to 140°, was effective in the correction of deformitiesover time.