Miguel Akkari

Trapezoidal Bony Correction of the Femoral Neck in the Treatment of Severe Acute-on-Chronic Slipped Capital Femoral Epiphysis

PURPOSE To present the first technical description of a modified surgical technique for trapezoidal bony correction of the femoral neck in the treatment of slipped capital femoral epiphysis (SCFE), performed entirely by arthroscopy. METHODS From December 2005 to January 2008, 5 patients with severe SCFE underwent trapezoidal femoral neck bone correction through arthroscopy. Their mean age at the time of surgery was 13.2 years. The time for postoperative follow-up ranged from a minimum of 12 months to a maximum of 39 months (mean, 26 months). The study analyzed data regarding the type of slip, degree of correction obtained, clinical and functional outcomes, and complications. RESULTS Analysis with the modified Harris Hip Score criteria showed a mean of 17.2 points preoperatively and 86.6 points at the last assessment. The mean epiphyseal deviation ranged from 82° at the initial presentation to 14° postoperatively. There were no intraoperative complications, and there was 1 case of avascular necrosis. CONCLUSIONS Arthroscopic treatment of SCFE resulted in correction of the angles of epiphyseal slip (from a mean epiphyseal-diaphyseal angle of 82° before surgery to 14° after surgery), with no immediate complications and 1 case of a late complication (avascular necrosis) in this 5-patient series. Clinical improvement was shown by a mean 69.4-point increase in the modified Harris Hip Score. LEVEL OF EVIDENCE Level IV, therapeutic case series.

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

EPIDEMIOLOGIA DAS FRATURAS DE FACE EM CRIANÇAS NUM PRONTO-SOCORRO DE UMA METRÓPOLE TROPICAL

OBJECTIVE: To conduct an epidemiological study of facial fractures in children in an emergency room. METHODS: A retrospective study of forty-two patients, aged zero to 17 years, with facial fractures treated at the Department of Oral and Maxillofacial Surgery, Santa Casa de Sao Paulo, from January 2000 to December 2003. The data were tabulated from information retrieved from patient files, such as age, gender, type of fracture, etiology and season of occurrence. RESULTS: Among the results were a predominance of males, accounting for 81% of all cases; jaw fracture was the most prevalent, constituting more than 70% of cases; and traffic accidents and falls were the etiologic agents that caused the most fractures. Summer was the season with the greatest number of cases of fracture and more than 80% required surgical intervention for their treatment. CONCLUSION: A policy of prevention is necessary, with special attention to traffic accidents and falls, which were the etiologic agents that caused the most facial fractures.

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.

Pseudartrose congênita de clavícula

A pseudartrose congenita de clavicula (PCC) e uma afeccao rara, que representa um disturbio na uniao dos nucleos de ossificacao e que pode ser diagnosticada ao nascimento. E mais comum em meninas e do lado direito. Este trabalho tem por objetivo proceder a uma revisao bibliografica sobre o tema, em pesquisa realizada nas bases de dados LILACS e MEDLINE. Foram encontrados 56 artigos publicados ate a corrente data. Apesar de pouco frequente, a PCC nao deve ser desconhecida ou mesmo esquecida, especialmente como diagnostico diferencial com a fratura aguda da clavicula por distocia de parto e/ou tocotraumatismo. O diagnostico e relativamente facil e o tratamento pode ser apenas expectante ou ate mesmo cirurgico.

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

PELVIC INJURY IN CHILDHOOD: WHAT IS ITS CURRENT IMPORTANCE?

ABSTRACT Objective: The purpose of this study was to assess the importance of pelvic fractures in childhood by analyzing epidemiological characteristics and associated injuries. Methods: This is a retrospective study performed between 2002 and 2012 at two trauma referral centers in São Paulo. We identified 25 patients aged 16 years old or younger with pelvic fracture. Results: The main mechanism of trauma was traffic accident (80%), followed by fall from height (16%). At hospital admission, 92% had traumatic brain injury and 40% had hemodynamic instability. Besides pelvic fractures, 56% of the children had other associated injuries (genitourinary, abdominal, vascular, chest and neurological), and 79% of them required operative treatment. According to the Torode and Zieg classification, the majority of cases were types III and IV. Seventy-two percent of all pelvic fractures were treated by surgery; 52% involved external fixation and 20% involved open reduction and internal fixation. Conclusions: The pelvic fractures in childhood can be considered a marker for injury severity, because the associated injuries usually are severe, needing operative treatment and leading to a high mortality rate (12%). Level of Evidence IV, Case Series.

Accidents due to falls from roof slabs.

CONTEXT AND OBJECTIVE Falls from the roof slabs of houses are accidents of high potential severity that occur in large Brazilian cities and often affect children and adolescents. The aims of this study were to characterize the factors that predispose towards this type of fall involving children and adolescents, quantify the severity of associated lesions and suggest preventive measures. DESIGN AND SETTING Descriptive observational prospective longitudinal study in two hospitals in the metropolitan region of São Paulo. METHODS Data were collected from 29 cases of falls from roof slabs involving children and adolescents between October 2008 and October 2009. RESULTS Cases involving males were more prevalent, accounting for 84%. The predominant age group was schoolchildren (7 to 12 years old; 44%). Leisure activities were most frequently being practiced on the roof slab at the time of the fall (86%), and flying a kite was the most prevalent game (37.9%). In 72% of the cases, the children were unaccompanied by an adult responsible for them. Severe conditions such as multiple trauma and traumatic brain injuries resulted from 79% of the accidents. CONCLUSION Falls from roof slabs are accidents of high potential severity, and preventive measures aimed towards informing parents and guardians about the dangers and risk factors associated with this type of accident are needed, along with physical protective measures, such as low walls around the slab and gates with locks to restrict free access to these places.