Nei Botter Montenegro

Anterograde removal of broken femoral nails without opening the nonunion site: a new technique

OBJECTIVE: We describe a new technique for removing the distal fragments of broken intramedullary femoral nails without disturbing the nonunion site. METHODS: This technique involves the application of an AO distractor prior to the removal of the nail fragments, with subsequent removal of the proximal nail fragment in an anterograde fashion and removal of the distal fragment through a medial parapatellar approach. Impaction of the fracture site is then performed with a nail that is broader than the remaining fragmented material. RESULTS: Nails were removed from five patients using the technique described above without any complications. After a mean follow-up period of 61.8 months, none of these patients showed worsened knee osteoarthritis. CONCLUSION: The original technique described in this article allows surgeons to remove the distal fragment of fractured femoral intramedullary nails without opening the nonunion focus or using special surgical instruments.

Comparative Study of Ilizarov, Wagner, and Anderson Methods for Limb Lengthening (100 Lengthenings in 98 Patients)

Summary One hundred lower limb lengthenings were performed in 98 patients by the Anderson (25 tibias, group A), Wagner (45 femurs, group B), and Ilizarov (16 femurs and 14 tibias, group C) methods in the Department of Orthopaedic and Traumatologic Surgery of the University of Sao Paulo School of Medicine from 1971 to 1991. Results obtained with the three methods, problems and complications observed, and comparison of healing time between the methods of lengthening used are reported. In group A, lengthening ranged from 3 to 6 cm (average 4.2 cm); healing time ranged from 121 to 331 days (average 196.88 days), with an average lengthening index of 1.72 months/cm. In group B, femoral lengthening ranged from 1 to 12.5 cm (average 4.6 cm); average healing time for group Bl (percutaneous osteotomy) was 185.4 days, and lengthening index was 1.32 months/cm; healing time for group B2 (corticotomy) was 156.3 days, with lengthening index of 1.23 months/cm. In group C, femoral lengthening ranged from 1.0 to 7.5 cm (average 4.7 cm), and healing time ranged from 58 to 441 days (mean of 185.6 days); the lengthening index was 1.31 months/cm. For Ilizarov tibial lengthening, lengthening ranged from 1.0 to 7.5 cm (average 4.5 cm), healing time ranged from 94 to 386 days (mean of 184 days), lengthening index was 1.35 months/cm. With the Anderson method, the most common complication was delayed union; with the Wagner technique, the most common complications were related to bone healing (fracture, implant failure after the second stage, nonunion); and with the Ilizarov method, the most common complication was incomplete corticotomy. Overall results were good despite the complications, and we emphasize the necessity for the surgeon to understand the principles of leg lengthening to achieve good results.

MAGNETIC RESONANCE IMAGING FOR DIAGNOSING THE PRE-SLIP STAGE OF THE CONTRALATERAL PROXIMAL FEMORAL EPIPHYSIS IN PATIENTS WITH UNILATERAL EPIPHYSIOLYSIS

To assess the importance of using conventional magnetic resonance imaging and T2 mapping to determine the pre-slip stage of the contralateral epiphysis in patients with a clinical and radiographic diagnosis of unilateral proximal femoral epiphysiolysis who were initially treated with in-situ fixation. Methods: This prospective clinical study on 11 patients with unilateral epiphysiolysis was conducted between February 2009 and August 2010, using magnetic resonance imaging on the contralateral hip. Results: We observed abnormalities in the proximal femoral capital physis of the contralateral unaffected hip, with edema under the growth plate in 27% of the patients assessed. Conclusion: Magnetic resonance imaging is an early and sensitive method for detecting the pre-slip stage of the proximal femoral epiphysis.

Ressonância magnética no diagnóstico do pré-escorregamento da epífise femoral proximal contralateral em pacientes com epifisiólise unilateral

OBJETIVO: Avaliar a importância da ressonância magnetica convencional e com mapa T2 na determinacao do pre-escorregamento da epifise contralateral em pacientes com diagnostico clinico e radiografico de epifisiolise femoral proximal unilateral, tratadas inicialmente com fixacao in situ. METODOS: Estudo clinico prospectivo de 11 pacientes com epifisiolise unilateral entre fevereiro de 2009 e agosto de 2010, com ressonância magnetica do quadril contralateral. RESULTADOS: Verificamos alteracoes na regiao fisaria capital femoral proximal no lado contralateral a doenca, com edema sob a placa de crescimento em 27% dos pacientes analisados. CONCLUSAO: A ressonância magnetica e um metodo sensivel e precoce para deteccao do pre-escorregamento epifisario femoral proximal.

Osteotomia de Dega modificada no tratamento da displasia do desenvolvimento do quadril.

ABSTRACT Objective: To retrospectively evaluate the preliminary postoperative results of modified Dega-type acetabular osteotomy to treat developmental dysplasia of the hip, confirming the efficacy and reproducibility of this technique. Methods: This retrospective study included patients older than 18 months. A total of 19 hips underwent modified Dega osteotomy. Results: Satisfactory results were obtained, with an average decrease of the acetabular index from 39.2 to 20.6 degrees. The final average center edge angle was 29.6 degrees. Hip joint congruence was reestablished in all cases, and as of this writing, only one case developed necrosis in the femoral head during follow-up. Conclusion: Modified Dega osteotomy demonstrated good initial results, as well as the potential for use in treating developmental dysplasia of the hip. Level of Evidence IV; Case series.

Initial experience of use of an articulated external fixator in treating Legg-Calvé-Perthes disease by means of arthrodiastasis during the active phase of the disease

Objective To present the preliminary results from treating patients with Legg-Calvé-Perthes Disease (LCPD) by means of hip arthrodiastasis using a monolateral external fixator applied to the hip and to succinctly describe the surgical technique used, in a prospective study. Methods Prospective study on 18 patients with LCPD who underwent surgical treatment by means of the hip arthrodiastasis technique using a monolateral external fixator. There were 13 male and five female patients of mean age 8.5 years, ranging from five to 13 years. All the patients presented unilateral hip impairment: nine on the right side and nine on the left. The results were evaluated at maturity using clinical and radiological criteria. Results All the patients evolved with improvement of joint mobility, and pain relief was achieved in 88.9% of them. Reossification of the femoral epiphysis occurred within the first three months of the treatment. The hips operated at the necrosis stage of the disease did not passed through the fragmentation stage, thus shortening the evolution of the disease. The results were 77.8% satisfactory and 22.2% unsatisfactory. Conclusion Hip arthrodiastasis with a monolateral external fixator during the active phase of LCPD improved the degree of joint mobility. Use of the arthrodiastasis technique at the necrosis stage or at the fragmentation stage (active phase of the disease) presented satisfactory results from treatment of LCPD.

MANAGEMENT OF INFANTILE BLOUNT'S DISEASE WITH MOLDED ORTHOSES: A NEW PERSPECTIVE

Objective : This retrospective study evaluated treatment with individually contoured molded bracing at early stages of the disease. Methods : We evaluated the medical records of patients undergoing treatment of Blounts disease with molded orthoses for medial decompression between 2010 and 2014. The deformity angle (Drennans metaphyseal-diaphyseal angle) and Langenskiöld classification were measured before and after treatment by a pediatric orthopedic surgeon with over 5 years of practice, blinded for the study and patients. Results : The mean age was 2.57 years old. Four patients were female and six male. Half of the total sample had bilateral disease. The average deformity angle showed a statistically significant reduction after treatment (p <0.001). Gender and laterality did not statistically influence the change of the deformity angle after treatment (p> 0.05). Conclusion : The nightly use of molded orthoses for medial decompression was effective in reducing the metaphyseal-diaphyseal angle in Blounts disease in children under 3 years of age, regardless of gender and bilateral disease. Patients over 3 years old did not benefit from bracing. Level of Evidence IV, Case Series.

Artrodiastase para o tratamento da rigidez do quadril na artrite reumatoide juvenil (ARJ): resultados preliminares

OBJETIVO: Apresentar os resultados preliminares da utilizacao da artrodiastase do quadril em pacientes portadores de artrite reumatoide juvenil e com comprometimento da articulacao coxofemoral. METODOS: Estudo prospectivo de 12 pacientes (seis meninos e seis meninas) com idades entre oito e 18 anos (media de 10,5 anos). Foi utilizado um fixador externo monolateral que permite os movimentos de flexao e de extensao no quadril. O fixador externo foi mantido por um periodo que variou de 78 a 90 dias, com media de 86 dias. O controle radiografico foi realizado durante o ato operatorio e, semanalmente, durante o periodo de tracao e a cada quatro semanas, quando terminado este periodo. Na avaliacao clinica dos resultados, incluimos a graduacao da dor e o grau de movimentacao articular, com medidas e avaliacoes pre e pos-operatorias. O periodo de acompanhamento variou de 12 a 15 anos, com media de 13 anos. RESULTADOS: O valor medio da escala de dor foi de nove (9) antes da operacao e de quatro (4) no periodo pos-operatorio. Em dois pacientes nao ocorreu melhora da dor. O arco de movimento do quadril aumentou em todos os pacientes, com excecao de dois. Na avaliacao radiografica evidenciamos um aumento no espaco articular de 2mm, em media, e que se manteve no pos-operatorio. Nao foram observadas complicacoes com a utilizacao da tecnica. Apenas verificamos soltura dos pinos de Schanz da regiao do osso iliaco em dois pacientes. A tecnica operatoria nao ocasionou resultado satisfatorio. CONCLUSAO: O procedimento de artrodiastase esta bem indicado para a recuperacao da mobilidade em uma articulacao coxofemoral comprometida e rigida, como ocorre em pacientes com artrite reumatoide juvenil.