Túlio Diniz Fernandes

Talocalcaneal coalition: diagnosis and surgical management.

The authors studied 22 patients who had 32 feet with symptomatic talocalcaneal coalition. All feet were treated with excision of the bar and interposition of an autogenous free fat graft. These cases were assessed clinically and radiographically before and after the operation. They conclude that this technique is a good surgery with gratifying results. In the final outcome, 78.1% of feet became completely painless and 21.8% achieved relief of pain. There was improvement of the deformity in 68.7% and of range of motion in 75%.

Changes in histoanatomical distribution of types I, III and V collagen promote adaptative remodeling in posterior tibial tendon rupture

INTRODUCTION Posterior tibial tendon dysfunction is a common cause of adult flat foot deformity, and its etiology is unknown. PURPOSE In this study, we characterized the morphologic pattern and distribution of types I, III and V collagen in posterior tibial tendon dysfunction. METHOD Tendon samples from patients with and without posterior tibial tendon dysfunction were stained by immunofluorescence using antibodies against types I, III and V collagen. RESULTS Control samples showed that type V deposited near the vessels only, while surgically obtained specimens displayed type V collagen surrounding other types of collagen fibers in thicker adventitial layers. Type III collagen levels were also increased in pathological specimens. On the other hand, amounts of collagen type I, which represents 95% of the total collagen amount in normal tendon, were decreased in pathological specimens. CONCLUSION Fibrillogenesis in posterior tibial tendon dysfunction is altered due to higher expression of types III and V collagen and a decreased amount of collagen type I, which renders the originating fibrils structurally less resistant to mechanical forces.

Vascular Density of the Posterior Tibial Tendon: A Cadaver Study

Background: Degenerative pathology of the posterior tibial tendon, a common cause of foot and ankle dysfunction, frequently affects women over 40 years of age. Its etiology is still controversial. The literature reports decreased vascularization coinciding with the most common site of the lesion, near the medial malleolus. Methods: Forty pairs of PTT obtained from human cadavers were transversally cut into six levels, from the musculotendon transition to its insertion point. In each segment, a histologic cut was made and stained with Massons trichrome allowing viewing of the vascular structure of the tendon under a light microscope. By using an integrating eyepiece on the microscope, vascular density was calculated. This verified any variation of the vascular concentration in the normal tendon, a possible cause of its degeneration. Results: When the results were compared by side, sex, and age, no statistically significant difference was observed. When the levels were compared, no area of decreased vascularization was seen in the midportion of the tendons, the most common site of degeneration of the posterior tibial tendon. Conclusion: These results indicate that an area of decreased vascularity is not a factor in degeneration of the posterior tibial tendon at the medial malleolus.

Charcot foot: Skin temperature as a good clinical parameter for predicting disease outcome

Twenty-eight diabetics presenting with acute Charcot foot were immobilized and the temperature difference between limbs measured at each month. All patients had monthly follow-up visits for a year and the relapse rate was zero. We found that skin temperature is a good parameter to ensure safe immobilization withdrawal.

MMP‐1 promoter polymorphism is associated with primary tendinopathy of the posterior tibial tendon

Posterior tibial tendon (PTT) dysfunction is recognized as an etiology leading to acquired flatfoot in adults, causing significant functional loss. Many risk factors and systemic conditions have been proposed in literature. However, many patients present PTT dysfunction without any of these characteristics. This suggests that there could be a genetic influence associated with posterior tibial tendinopathy. The purpose of the present study is to investigate the association of the −1607 polymorphism in the promoter gene of MMP‐1 and posterior tibial tendinopathy. The test group included 50 women, who presented PTT dysfunction grade 2 or 3, and who were submitted to surgical treatment, with histopathological examination of the tendon and magnetic resonance image (MRI) confirming tendinopathy, while the control group was 100 asymptomatic women who presented intact PTT at MRI. The results were analyzed using the chi‐square test. The data showed a 75% incidence of the allele 1G and 62% of the genotype 1G/1G at the control group while, at the test group, they showed a 78% incidence of the allele 2G and 72% of the genotype 2G/2G (p < 0.001). The −1607 polymorphism of promoter gene of MMP‐1 is associated with the posterior tibial tendinopathy in the studied population.

MMP‐8 polymorphism is genetic marker to tendinopathy primary posterior tibial tendon

Posterior tibial tendon is particularly vulnerable and is responsible for much morbidity in sportspersons. Some patients have a predisposition without a clinically recognized cause, suggesting that individual characteristics, inclusive genetic inheritance, play an important role in tendinopathy. Matrix metalloproteinase (MMP)‐8 is a proteinase capable of degrading a large amount of extracellular proteins, and influence degradation and remodeling of collagen. To determine whether the −799 polymorphism in the promoter of MMP‐8 gene is associated with tendinopathy in posterior tibial tendon, 50 patients undergoing surgical procedures and anatomopathological diagnosis of degenerative lesions of the posterior tibial tendon and 100 control patients with posterior tibial tendon integrity and without signs of degeneration in magnetic resonance imaging were evaluated for the −799 MMP‐8 polymorphism. There was a significant difference in the presence of the different alleles (P = 0.001) and genotype (P = 0.003) between the control group and the test group for the MMP‐8 gene. The polymorphism at position −799 of the gene for MMP‐8 is associated with tendinopathy primary posterior tibial tendon in the population studied. The results suggest that individuals with the T allele are at greater risk of developing tendinopathy.

A Comparative, Prospective, and Randomized Study of Two Conservative Treatment Protocols for First-episode Lateral Ankle Ligament Injuries

Background: The objective of this study was to investigate functional results, the amount of time that patients missed from regular working activities, and the incidence of residual mechanical ankle instability following conservative treatment of a first episode of severe lateral ankle ligament sprain (with articular instability). Methods: This prospective and randomized study included 186 patients with severe lateral ankle ligament injuries, who were randomly assigned into 2 conservative treatment groups. In group A, participants were treated with a walking boot with weight-bearing allowed, pain management, ice, and elevation with restricted joint mobilization for 3 weeks. In group B, patients were treated with a functional brace for 3 weeks. After this period, patients from both groups were placed in a short, functional brace for an additional 3 weeks, during which they also started a rehabilitation program. Results: No statistically significant difference was found in pain intensity score between the 2 groups; however, functional evaluations based on the AOFAS ankle and hindfoot score system showed a statistically significant improvement in the group treated with the functional brace. In addition, the average recovery period necessary for patients of group B to resume their duties was shorter than that for patients in group A. No significant difference was detected in residual mechanical ankle instability between the 2 groups. Conclusion: Patients with severe lateral ankle ligament lesions treated with a functional brace were shown to exhibit somewhat better results than those treated with a walking boot, and both methods presented a very low incidence of residual chronic instability. We found adequate conservative treatment was sufficient to reestablish ankle stability and that functional treatment had a marginally better clinical short-term outcome with a shorter average recovery period. Level of Evidence: Level I, prospective randomized study.

Cartilage lesions and ankle osteoarthrosis: review of the literature and treatment algorithm,

The main etiology of ankle osteoarthrosis is post-traumatic and its prevalence is highest among young individuals. Thus, this disease has a great socioeconomic impact and gives rise to significant losses of patients’ quality of life. The objective of its treatment is to eliminate pain and keep patients active. Therefore, the treatment should be staged according to the degree of degenerative evolution, etiology, joint location, systemic condition, bone quality, lower-limb alignment, ligament stability and age. The treatment algorithm is divided into non-surgical therapeutic methods and options for surgical treatment. Joint preservation, joint replacement and arthrodesis surgical procedures have precise indications. This article presents a review on this topic and a proposal for a treatment algorithm for this disease.

Hállux Rígidus: estudo prospectivo da substituição articular com hemiartroplastia

OBJECTIVE: To report the results of medium-term follow-up after deploying Arthrosurface-HemiCap(r) in patients with diagnosis of Hállux Rigidus (HR). METHOD: Eleven patients underwent partial Arthroplasty of the first metatarsal-phalangeal joint. Six women and five men with an average age 51.9 years (46 to 58 years) and average postoperative follow-up of 3.73 years (3-4 years); were classified through the Kravitz system and evaluated by the American Orthopaedic Foot and Ankle Society (AOFAS) scales for hállux, Visual Analogical Scale (VAS) - analog functional pain - and range of motion in the first metatarsal joint in preoperative, postoperative after six months and present post-operative. RESULTS: The results show significant improvement of the three analyzed parameters, both for overall analysis and for pre and post-operative comparisons individually. The comparative analysis of each variable in the six months and the current postoperative periods do not show statistically significant differences, indicating maintenance of parameters during this interval. CONCLUSION: hemiarthroplasty of first metatarsophalangeal joint is a reproducible and safe option for the surgical treatment of hállux rigidus II and III, with significant improvement of the evaluated parameters for the studied population. Level of Evidence IV, Case Series.

Fatores preditivos da marcha em pacientes diabéticos neuropático e não neuropáticos

OBJECTIVE: The purpose of this study was to analyze the range of movement of the ankle and the vertical ground reaction force involved in gait among diabetic patients with and without peripheral neuropathy. SAMPLE AND METHOD: 36 individuals were divided into three groups: Control group - CG: 10 individuals without diabetes, Diabetic group - DG: 10 individuals with diabetes without peripheral neuropathy and Neuropathy, and Diabetic neuropathic group - DNG: 16 individuals with diabetes and peripheral diabetic neuropathy. Gait - AMTI® OR6/6m and range of tibiotarsal joint movement - System Vicom 640® was carried out in all the participants. RESULTS: The first and second vertical ground reaction force peaks were statistically higher in the neuropathy group, and the range of ankle motion was lower in the Diabetes and Neuropathy groups. CONCLUSION: The range of movement of the tibiotarsal joint is lower in diabetics, regardless of the presence or absence of peripheral neuropathy, and diabetics with peripheral neuropathy show an increase in the first and second vertical ground reaction force peaks during walking.