PROXIMAL TIBIAL OSTEOTOMY: STABILIZATION OF THE MEDIAL OPENING WITH A TRICORTICAL ILIAC BONE GRAFT.

OBJECTIVE: Radiographic assessment of lower limb alignment, in the frontal and sagittal planes, after high tibial osteotomy. To stabilize the osteotomy, a tricortical iliac graft was used, along with a positioning screw. METHODS: Prospective study on 46 patients with ages ranging from 17 to 61 years. Among them, 42 patients presented genu varum secondary to knee osteoarthritis and four from other causes. Teleradiography was performed for surgical planning, using the Frank Noyes method, as modified by Fugizawa. A conventional surgical access of 3 cm was made to harvest a tricortical iliac graft. Osteotomy was performed under radioscopic control, by means of an anteromedial incision of 3 cm with release of the superficial portion of the medial collateral ligament. The graft was placed in the posterior portion of the osteotomy, to maintain an unaltered tibial slope. The screw crossed the osteotomy orthogonally to protect the lateral cortex. Pre and postoperative radiographic criteria were established to assess the results. RESULTS: There was consolidation in 100% of the cases and maintenance of the mechanical axis, obtained intraoperatively, in 94% of the cases. The posterior slope of the tibial plateau in the sagittal plane ranged from 7° to 12°. Joint mobility was restored in all the patients. Eleven patients presented temporary pain at the site of graft harvesting, but none had paresthesia. The incidence of complications was 8% (infection, loss of correction and joint fracture). CONCLUSION: The technique was shown to be reproducible, simple, biological, accurate and low-cost, and it may be an alternative to the existing techniques.

Osteotomia proximal da tíbia: estabilização da abertura medial com enxerto tricortical de ilíaco / Proximal tibial osteotomy: stabilization of the medial opening with atricortical iliac bone graft

OBJETIVO: Avaliação radiográfica do alinhamento do membro inferior, nos planos frontal e sagital, após osteotomia alta da tíbia. Para estabilização da osteotomia foi utilizado enxerto tricortical de ilíaco e parafuso de posicionamento. MÉTODOS: Estudo prospectivo envolvendo 46 pacientes com idade entre 17 e 61 anos, sendo 42 portadores de geno varo secundário à osteoartrose e quatro por outras causas. A telerradiografia foi realizada para planejamento cirúrgico, utilizando o método de Frank Noyes modificado por Fugizawa. Foi realizado acesso cirúrgico convencional de 3cm para retirada do enxerto tricortical de ilíaco. A osteotomia foi realizada sob controle de radioscopia, por incisão anteromedial de 3cm com liberação da porção superficial do ligamento colateral medial. O enxerto foi colocado na porção posterior da osteotomia, para manter inalterado o slope tibial. O parafuso cruzou a osteotomia ortogonalmente para proteger a cortical lateral. Foram estabelecidos critérios radiográficos pré e pós-operatórios para avaliação dos resultados. RESULTADOS: Houve consolidação em 100 por cento dos casos e manutenção do eixo mecânico, obtido no intraoperatório, em 94 por cento. A inclinação posterior do platô tibial, no plano sagital, variou entre 7º e 12º. A mobilidade articular foi restabelecida em todos os pacientes operados. Onze pacientes apresentaram dor temporária no local da retirada do enxerto; no entanto, nenhum apresentou parestesia. A incidência de complicações foi de 8 por cento (infecção, perda da correção, fratura articular). CONCLUSÃO: A técnica mostrou-se reprodutível, simples, biológica, precisa e com baixos custos, podendo ser uma alternativa às técnicas já existentes.

OBJECTIVE: Roentgenographic assessment of lower limb alignment, in the frontal and sagittal planes, after a high tibial osteotomy. To stabilize the osteotomy, a tricortical iliac graft was used along with a positioning screw. METHODS: Prospective study of 46 patients with ages ranging from 17 to 61 years. Among them, 42 patients were carriers of genu varum secondary to knee osteoarthritis and four from other causes. Radiography was performed for surgical planning, using the Frank Noyes method modified by Fugizawa. Three cm conventional surgical access was performed to remove a tricortical iliac graft. The osteotomy was performed under fluoroscopic control, by 3 cm anteromedial incision with release of the superficial portion of the medial collateral ligament. The graft was placed in the posterior portion of the osteotomy to maintain an unaltered tibial slope. The screw crossed the osteotomy orthogonally to protect the lateral cortex. Radiographic criteria were established pre-and postoperatively to assess the results. RESULTS: There was consolidation in 100 percent of cases and maintenance of the mechanical axis, obtained intraoperatively in 94 percent of cases. Correction of mechanical axis occurred in 94 percent (43 patients / 47 osteotomies). The posterior slope of the tibial plateau in the sagittal plane ranged from 7º to 12º. Joint mobility was restored in all patients. Eleven patients had temporary pain at the site of graft removal, however, none had paraesthesia. The incidence of complications was 8 percent (infection, loss of correction, joint fracture). CONCLUSION: This technique is reproducible, simple, biologic, accurate, low-cost, and can be used as an alternative to existing techniques.

Not telling the truth in the patient-physician relationship.

The presence of truth and honesty is a permanent demand, and becomes vital the more committed and intimate a relationship is. Medical practice is relevant to this discussion when one questions whether or not a physician should always tell their patient the truth in the face of a progressive or potentially fatal disease, regarding their diagnosis, outcome, therapy and evolution of the specific disease. From this discussion we aim, with the present report, to look at the truth applicable to the patient-physician relationship, and its ethical and moral implications; and also to look at where the Brazilian Code of Medical Ethics (BCME) and the medical literature stand regarding this issue. One concludes that there are only two moments not to tell a patient the truth: when the patient does not want to be informed, and when the truth could be iatrogenic. The question now is, when would the truth be iatrogenic? Physicians, in our opinion, would not be able to judge solitarily when the truth might be deleterious to their patient. Alternatively, we proposed the appointment of a multidisciplinary commission to help the doctor with such a decision.