Growth modulation for angular knee deformities: a practical guideline.

PURPOSE OF REVIEW: This study aimed to review the established concepts and advances related to growth modulation for treating knee angular deformities. Although they are considered well tolerated procedures, careful indications and accurate techniques are necessary to ensure good results. RECENT FINDINGS: In addition to general clinical and radiographic evaluations, new tools such as two-dimensional low-dose radiography and gait analysis have been used to clarify angular and torsional combinations and the impact of mild angulations on the knee joint. Temporary epiphysiodesis is commonly the choice, and it can be performed with different implants such as staples, tension band plates (TBP), percutaneous transphyseal screws (PETS), sutures, and screws. SUMMARY: Considering its principles, TBP has been preferred for younger children. Cost can be a limitation, and research for alternative implants such as screws and nonabsorbable sutures indicate they might be an alternative in the future. In adolescents, PETS becomes an attractive alternative; however, its reversible character has been controversial, and further studies are needed to establish limits in younger patients.

Tarsal coalition.

PURPOSE OF REVIEW: Tarsal coalitions may cause painful pes planovalgus and recurrent sprains, and can lead to arthrosis if improperly managed. In this review, we discuss the current topics related to talocalcaneal and calcaneonavicular coalitions. RECENT FINDINGS: Tarsal coalitions are initially managed with conservative therapy, and when this approach fails, surgery is performed. Treatment of calcaneonavicular coalitions involves resection of the coalition and interposition of the extensor digitorum brevis muscle or fat, and in cases of marked valgus deformity, correction of the deformity. In talocalcaneal coalitions, recommendations include coalition resection for those affecting less than 50% of the area of the posterior facet and with a less than 16° valgus, coalition resection and valgus correction for those affecting less than 50% of the area and valgus greater than 16°, and isolated valgus correction for those affecting more than 50% of the area and with a more than or less than 16° valgus. Arthrodesis is reserved as a salvage procedure. SUMMARY: Talocalcaneal and calcaneonavicular coalitions can cause painful pes planovalgus. Their diagnoses are confirmed by plain radiograph, computed tomography, and, in cases of fibrous or cartilaginous coalitions, MRI. Initial treatment is conservative, and when symptoms persist, resection of the coalition is recommended along with tissue graft interposition with or without associated valgus correction. Arthrodesis is indicated as a salvage procedure whenever treatment fails or with advanced arthrosis.

Chronic Monteggia.

PURPOSE OF REVIEW: The chronic Monteggia may lead to pain, mobility limitation, progressive valgus deformity, lateral elbow instability, late ulnar nerve paralysis, and degenerative changes. In this review, we discuss the current procedures in the literature focused on correcting chronic Monteggia to avoid these complications. RECENT FINDINGS: Correction of the ulnar deformity with elongation and angulation of the ulna in the opposite direction of the dislocation of the radial head is the most important factor for the reduction and consequent preservation of the radial head. This correction reestablishes the relation of the ulna with the radius and increases the space of the interosseous membrane, providing greater stability after the reduction. The correction may be performed in the acute phase and stabilized with a properly molded plate and screws, or done progressively with an external fixator. SUMMARY: The chronic Monteggia may occur along with undiagnosed lesions, such as plastic deformation of the ulna with radial head dislocation, or after an unsuccessfully treated acute Monteggia lesion. This condition may go unnoticed, thus requiring attention to the physical examination and imaging tests. Chronic Monteggia may be treated by ulnar osteotomy with progressive correction with an external fixator. However, the most common treatment is transverse proximal ulnar osteotomy, capsulotomy and removal interposed tissue, reduction of the radial head to the capitellum and temporary transcapitellar fixation, ulnar fixation with a straight plate molded to the ulnar deformity, which is usually deviated dorsally, removal of the transcapitellar Kirschner-wire, stability test, and, if necessary, annular ligament reconstruction.

Surgical treatment of femoroacetabular impingement after slipped capital femoral epiphysis.

PURPOSE OF REVIEW: Femoroacetabular impingement (FAI) post slipped capital femoral epiphysis (SCFE) may lead to degenerative changes on the hip. We have reviewed the current procedures in the literature, aiming to correct the SCFE to prevent FAI and the ones that treat FAI post SCFE. RECENT FINDINGS: The trends of managing moderated or severe SCFE is to correct the displacement by reduction and fixation with articular hematoma decompression in unstable hips and Dunn modified procedure even for unstable and stable situations. However, after FAI is settled, the options are osteochondroplasty by arthroscopy or surgical hip dislocation, associated or not to subtrocanteric osteotomy. SUMMARY: Femoroacetabular impingement may occur in mild slips and certainly occur in cases of moderate and severe slips. The initial management depends on the severity and the stability of the slip.The modified Dunn procedure is a good option for the treatment of unstable SCFEs. Gentle closed reduction with capsulotomy (Parsch) may be considered whenever the surgeon is not comfortable with the modified Dunn procedure.Hips with open physis and stable moderate or severe SCFE, the modified Dunn procedure can be indicated. Cases with closed physis are managed with intertrochanteric osteotomy combined with osteoplasty.In the presence of symptomatic FAI secondary to SCFE, one should consider arthroscopic osteoplasty or surgical hip dislocation (with or without osteotomies) as treatment options.

Tratamento das fraturas do olécrano em crianças / Treatment of olecranon fractures in children

As fraturas do olécrano em crianças são relativamente incomuns, totalizando 4 a 6 por cento de todas as fraturas do cotovelo; a maioria é de tratamento conservador. Especial interesse é relatado na literatura quanto às indicaçães de tratamento cir£rgico nessas lesães. No per¡odo de janeiro de 1996 a maio de 1997, os autores atenderam em seu serviço 17 casos de fraturas de olécrano em crianças (entre 4 e 13 anos); 11 foram tratadas conservadoramente e 6, submetidas a tratamento cir£rgico. Ap¢s média de seguimento de 4,9 meses, 16 pacientes apresentaram resultados satisfat¢rios e apenas um, rigidez e deformidade articular. Os autores acreditam que a diástase maior ou igual a 3mm entre os fragmentos seja bom critério para indicação do tratamento cir£rgico das fraturas fechadas do olécrano nas crianças.

Osteólise idiopática com transmissäo hereditária autossômica dominante: relato de 3 casos / Idiopatic osteolysis with autosomal dominant inheritance transmission: report of 3 cases

Os autores apresentam os resultados obtidos com o tratamento cirúrigco do torcicolo muscular congênito em 34 pacientes livres de qualquer tratamento anterior que foram submetidos a liberaçao proximal e distal do músculo esternoclidomastóideo. Destes, 20 eram do sexo masculino e 14, do feminino. A idade mínima quando da realizaçao do procedimento foi de dois anos e seis meses e a máxima, de quinze anos e nove meses, sendo que o seguimento variou de quatro meses a quatro anos e onze meses. Foram observados aspectos quanto à gestaçao, aprto, tocotraumatismos e outras associaçoes. A ausência de imobilizaçao no pós-operatório e o início precoce da cinesioterapia, além de serem bem tolerados pelos pacientes, mostraram-se importantes para a evoluçao do tratamento. Os autores concluem que quanto mais jovem o paciente no momento da cirurgia, melhor será o resultado cosmético; observam, porém, que nao há contra-indicaçao para pacientes com mais idade, pois a melhora funcional ocorreu em todos os casos.

Talectomia no tratamento das deformidades rígidas dos pés na artrogripose e sequela de mielomeningocele / Talectomy for the treatment of rigid deformitis of the foot in arthrogryposis and in sequelae of myelomeningocele

No período entre 1984 e 1992, 21 pacientes (38 p,s) com deformidades rígidas nos pós portadores de artrogripose e seqüela de mielomeningocele foram tratados com talectomia associada à liberaçäo póstero-medial. O objetivo da talectomia foi a obtençäo de pós plantígrados capazes de utilizar calçados normais ou ortopédicos. A idade média na ocasiäo da cirurgia foi de três anos e seis meses (mínima de nove meses e máxima de oito anos e seis meses). O tempo de seguimento médio foi de três anos e seis meses (mínimo de seis meses e máximo de oito anos). Os resultados foram analisados pelo critério clínico, obtendo-se 29 pés (76 por cento) com correçäo satisfatória e nove pés (24 por cento) considerados insatisfatórios, nos quais houve recidiva das deformidades. A talectomia, um procedimento útil nas crianças com deformidades graves e rígidas portadoras de artrogripose e seqüela de mielomeningocele.