Republication of "Minimally Invasive Surgery Using the Circular External Fixator to Correct Neglected Severe Stiff Equinocavus Foot Deformities".

Background: Stiff equinocavus deformities of the foot are challenging to treat, often requiring extensive soft tissue dissection and bone removal. These procedures frequently yield suboptimal results and not infrequently amputation. Minimally invasive surgery using a circular external fixator potentially avoids the trauma to the soft tissue and may lead to improvement in outcomes and a lower amputation rate. The objective of this study was to evaluate the efficacy of minimally invasive surgery using a circular external fixator and limited soft tissue release to correct stiff equinocavus deformities. Methods: The treatment outcome of 29 patients (31 feet) with stiff equinocavus deformities of the foot and ankle treated with minimally invasive surgery and circular external fixation were reviewed after a mean follow-up period of 63 months. Patients' demographics and cause of the deformities were recorded. Weight bearing radiographs of the foot were compared pre and postoperatively. Results: Outcome was satisfactory (plantigrade foot with improvement/resolution of pain) in 21 of 31 extremities, fair in 6 of 31 extremities, and poor in 4 of 31 extremities. In the majority of patients, a significant improvement in the equinocavus deformities was achieved with a statistically significant improvement in calcaneus and navicular height. Two patients with Charcot-Marie-Tooth and severely insensate feet had a poor outcome, resulting in transtibial amputation. Conclusion: Minimally invasive surgery with gradual correction of neglected stiff equinocavus deformities using a modular circular external fixator is a reliable initial limb salvage strategy. Minimally invasive surgery and gradual correction of neglected severe stiff equinocavus deformities using the modular circular external fixator to gradually correct neglected severe stiff equinocavus deformities, is a safe initial limb salvage strategy which may simplify secondary procedures such as arthrodesis. Level of evidence: IV.

Anterior tibial tendon transfer in idiopathic clubfoot: does the outcome differ with the initial treatment? Proposed classification to surgical indication.

PURPOSE: To establish parameters and propose a radiographic classification for foot adduction/supination deformities to assist the indication of Garceau procedure. Secondly, to investigate whether the outcome of Garceau surgery depends on the initial treatment used, peritalar release, or the Ponseti method, and verify the maintenance of correction until skeletal maturity. METHODS: Prospective cohort study, with follow-up evaluations in 2009 and 2019. Fifty-three consecutive patients (71 feet) with idiopathic congenital clubfoot (ICCF) were divided into two groups according to the initial treatment used: peritalar release (group I) or Ponseti method (group II). All patients underwent Garceau procedure. The patients were evaluated clinically and radiographically using the American Orthopedic Foot Association (AOFAS) score for ankle and hindfoot. A radiographic classification is proposed based on the adduction by talo-first metatarsal angle on dorsoplantar view and supination by the elevation of the head of the first metatarsal on lateral view, both weight-bearing. RESULTS: In the first clinical evaluation, the mean score on the AOFAS was 87 points in group I and 86 points in group II. In the second evaluation, group I had mean AOFAS of 92 points and group II of 94 points. No statistical differences were found between the two groups, neither between the first and the second evaluation. In the radiographic evaluation, the adduction deformity obtained an average correction of 4° in group I and 3.6° in group II; in supination deformity, the average depression of the first metatarsal head in relation to the ground was 6.7 mm in group I and 7.5 mm in group II, with no statistical difference between the two evaluations, indicating the correction was maintained until skeletal maturity. CONCLUSION: Garceau transfer is capable of correcting residual deformities in adduction/supination of mild and moderate degrees, regardless of the initial treatment, and maintaining the correction until skeletal maturity. The proposed radiographic classification might help to objectively indicate the surgical procedure.

Diabetic Foot. Part 2: Charcot Neuroarthropathy.

Charcot neuroarthropathy (CN) is an unfortunate and common complication of patients with diabetes, most likely resulting from a lack of proper understanding of the disease, which leads to late diagnosis. It is commonly misdiagnosed as infection and treated with antibiotics and a frustrated attempt of surgical drainage, which will reveal only debris of the osteoarticular destruction. Proper education of diabetic patients and of the health care professionals involved in their treatment is essential for the recognition of the initial signs of CN. The general orthopedic surgeon is usually the first to treat these patients in the early stages of the disease and must be aware of the signs of CN in order to establish an accurate diagnosis and ensure proper treatment. In theory, this would make it possible to decrease the morbidity of this condition, as long as proper treatment is instituted early.

Diabetic Foot. Part 1: Ulcers and Infections.

Diabetes is a systemic disease that has achieved epidemic proportions in modern society. Ulcers and infections are common complications in the feet of patients with advanced stages of the disease, and are the main cause of amputation of the lower limb. Peripheral neuropathy is the primary cause of loss of the protective sensation of the feet and frequently leads to plantar pressure ulcers and osteoarticular disruption, which in turn develops into Charcot neuropathy (CN). Common co-factors that add to the morbidity of the disease and the risk of amputation in this population are obesity, peripheral arterial disease, immune and metabolic disorders. Orthopedic surgeons must be aware that the early detection and prevention of these comorbidities, through diligent medical care and patient education, can avoid these amputations.

Diabetic Foot. Part 1: Ulcers and Infections / Pé diabético. Parte 1: Úlceras e Infecções*

Abstract Diabetes is a systemic disease that has achieved epidemic proportions in modern society. Ulcers and infections are common complications in the feet of patients with advanced stages of the disease, and are the main cause of amputation of the lower limb. Peripheral neuropathy is the primary cause of loss of the protective sensation of the feet and frequently leads to plantar pressure ulcers and osteoarticular disruption, which in turn develops into Charcot neuropathy (CN). Common co-factors that add to the morbidity of the disease and the risk of amputation in this population are obesity, peripheral arterial disease, immune and metabolic disorders. Orthopedic surgeons must be aware that the early detection and prevention of these comorbidities, through diligent medical care and patient education, can avoid these amputations.

Resumo As úlceras e infecções são complicações comuns nos pés dos pacientes diabéticos que já se encontram na fase tardia desta doença sistêmica que se tornou uma verdadeira epidemia do mundo moderno. Neste grupo específico de pacientes, são as infecções que constituem o principal fator envolvido na sequência de eventos que resultam na amputação do membro inferior. A neuropatia periférica (NC) constitui fator determinante na perda da sensibilidade protetora dos pés na fase tardia da doença e, por sua vez, favorece o desenvolvimento das úlceras plantares de pressão (UPP) e a destruição osteoarticular causado pela neuroartropatia de Charcot (NC). A obesidade, a doença arterial periférica (DAP) e a deficiência no sistema imunológico devida aos distúrbios metabólicos do diabetes desempenham papel adicional importante na morbidade desta doença, principalmente no que se refere à amputação dos membros inferiores. É importante para o médico ortopedista compreender que para tentar evitar estas complicações que costumam resultar na amputação da extremidade é necessário estabelecer estratégias de prevenção direcionadas, principalmente, para a educação do paciente diabético e também para medidas protetoras profiláticas.

Diabetic Foot. Part 2: Charcot Neuroarthropathy / Pé diabético. Parte 2: Neuroartropatia de Charcot

Abstract Charcot neuroarthropathy (CN) is an unfortunate and common complication of patients with diabetes, most likely resulting from a lack of proper understanding of the disease, which leads to late diagnosis. It is commonly misdiagnosed as infection and treated with antibiotics and a frustrated attempt of surgical drainage, which will reveal only debris of the osteoarticular destruction. Proper education of diabetic patients and of the health care professionals involved in their treatment is essential for the recognition of the initial signs of CN. The general orthopedic surgeon is usually the first to treat these patients in the early stages of the disease and must be aware of the signs of CN in order to establish an accurate diagnosis and ensure proper treatment. In theory, this would make it possible to decrease the morbidity of this condition, as long as proper treatment is instituted early.

Resumo A neuropatia de Charcot (NC) é uma complicação lamentável e comum de pacientes com diabetes, provavelmente resutlante de uma falta de entendimento adequado dessa condição, que leva ao diagnóstico tardio.A confusão diagnóstica com quadro infeccioso contribui para que o tratamento inicialmente indicado seja equivocado ao prescrever medicação antibiótica ou, eventualmente, drenagem cirúrgica. Não é infrequente que a drenagem inadvertida do suposto abcesso revele que na verdade seu conteúdo é formado apenas de partículas provenientes da destruição osteoarticular. A educação adequada, tanto dos pacientes diabéticos quanto dos médicos responsáveis por prestar atendimento primário a estes pacientes, é fundamental para a correta compreensão das principais características relacionadas ao desenvolvimento da NC. O ortopedista geral é quem, na maioria das vezes, recebe no pronto atendimento os pacientes que se encontram na fase aguda inicial da doença. Por esta razão, esses profissionais devem estar extremamente alertas e serem capazes de identificar os primeiros sinais que permitem diagnosticar precocemente a NC. Em tese, isto possibilitaria reduzir a morbidade desta afecção na medida em que o tratamento adequado venha a ser precocemente instituído.

What is the Prognosis of Triple Arthrodesis in the Treatment of Adult Acquired Flatfoot Deformity (AAFD)?

Objective The present study aims to evaluate the ability of triple arthrodesis in eliminating the main complaints presented by patients with adult acquired flatfoot deformity (AAFD): 1) disabling hindfoot pain; 2) major deformities, such as medial arch collapse, valgus, abduction, and supination. Methods A total of 17 patients (20 feet) with advanced AAFD who underwent surgical correction by triple arthrodesis were evaluated after a mean follow-up period of 43 months (range: 18-84 months). The average age of the patients at surgery was 62 years old (range: 38-79 years old). The visual analogue scale (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score were used to assess the final results. Results According to the VAS, the average residual pain was 3 points; the AOFAS hindfoot score points increased 23% after the surgery; and the correction of deformities was considered satisfactory in 10 out of 20 feet; partially satisfactory in 4 out of 20 feet; partially unsatisfactory in 5 out of 20 feet; and unsatisfactory in 1 out of 20 feet. Conclusion Despite the high index of bone fusion after triple arthrodesis, which is the gold standard treatment in advanced AAFD, the incomplete correction of major deformities and the persistence of residual pain contributed to a high disappointment rate of the patients with the surgical results.

What is the Prognosis of Triple Arthrodesis in the Treatment of Adult Acquired Flatfoot Deformity (AAFD)? / Qual o prognóstico da artrodese tríplice quando utilizada no tratamento do pé plano adquirido do adulto (PPAA)?

Abstract Objective The present study aims to evaluate the ability of triple arthrodesis in eliminating the main complaints presented by patients with adult acquired flatfoot deformity (AAFD): 1) disabling hindfoot pain; 2) major deformities, such asmedial arch collapse, valgus, abduction, and supination. Methods A total of 17 patients (20 feet) with advanced AAFD who underwent surgical correction by triple arthrodesis were evaluated after a mean follow-up period of 43 months (range: 18-84 months). The average age of the patients at surgery was 62 years old (range: 38-79 years old). The visual analogue scale (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score were used to assess the final results. Results According to the VAS, the average residual pain was 3 points; the AOFAS hindfoot score points increased 23% after the surgery; and the correction of deformities was considered satisfactory in 10 out of 20 feet; partially satisfactory in 4 out of 20 feet; partially unsatisfactory in 5 out of 20 feet; and unsatisfactory in 1 out of 20 feet. Conclusion Despite the high index of bone fusion after triple arthrodesis, which is the gold standard treatment in advanced AAFD, the incomplete correction of major deformities and the persistence of residual pain contributed to a high disappointment rate of the patients with the surgical results.

Resumo Objetivo Avaliar a capacidade da artrodese tríplice de aliviar as principais queixas dos pacientes que apresentam pé plano adquirido do adulto (PPAA): 1) dor incapacitante localizada no médio e retropé; 2) deformidades marcadas pelo colapso do arco medial, valgo, abdução e supinação. Método Avaliamos 17 pacientes (20 pés) portadores de PPAA em estado avançado que foram submetidos à correção cirúrgica pela artrodese tríplice modelante. A média de idade dos pacientes no momento da cirurgia foi de 62 anos (variação de 38 a 79 anos), e o tempo médio de seguimento foi de 43 meses (variação de 18 a 84 meses). Utilizamos critérios clínicos empregando a escala visual analógica da dor (EVAD) e a escala funcional da American Orthopaedic Foot and Ankle Society (AOFAS, na sigla em inglês) do retropé para avaliar a eficácia da cirurgia. Resultados A dor residual mensurada pela EVAD foi de três pontos, em média. Observamos incremento médio de 23% nos valores da escala AOFAS do retropé após o tratamento cirúrgico. A correção das deformidades foi satisfatória em 10 de 20 pés; parcialmente satisfatória em 4 de 20 pés; parcialmente insatisfatória em 5 de 20 pés; e insatisfatória em 1 de 20 pés. Conclusão Apesar da artrodese tríplice modelante indicada no tratamento do PPAA em estágio avançado apresentar alto índice de consolidação óssea, a correção incompleta das deformidades pré-existentes e a persistência de dor residual contribuíram para a elevada taxa de decepção dos pacientes com o resultado da cirurgia.

Talalgia: plantar fasciitis / Talalgias: fascite plantar

Plantar fasciitis is a very common painful syndrome, but its exact etiology still remains obscure. The diagnosis is essentially clinical, based on history-taking and physical examination. Complementary laboratory tests and imaging examinations may be useful for differential diagnoses. The treatment is essentially conservative, with a high success rate (around 90%). The essence of the conservative treatment is the home-based program of exercises to stretch the plantar fascia. Indications for surgical treatment are only made when the symptoms persist without significant improvement, after at least six months of conservative treatment supervised directly by the doctor...

A fascite plantar é uma síndrome dolorosa muito frequente, mas sua exata etiologia ainda permanece obscura. O diagnóstico é essencialmente clínico e tem como base a história e o exame físico. Exames complementares laboratoriais e de imagem podem ser úteis no diagnóstico diferencial. O tratamento é essencialmente conservador, com elevada taxa de sucesso (ao redor de 90%). A essência do tratamento conservador é o programa domiciliar com exercícios para alongamento da fáscia plantar. A indicação do tratamento cirúrgico somente é feita quando os sintomas persistem sem melhoria significativa, após pelo menos seis meses de tratamento conservador supervisionado diretamente pelo médico...

Clinical and functional evaluation of forefoot reconstruction in patients with rheumatoid arthritis / Avaliação clínico-funcional da reconstrução do antepé nos pacientes portadores de artrite reumatoide

OBJECTIVE: to evaluate the long-term results from reconstruction of the forefoot in patients with rheumatoid arthritis who underwent arthrodesis of the metatarsophalangeal joint of the hallux, resection arthroplasty of the heads of the lateral metatarsals and correction of the deformities of the smaller toes through arthrodesis of the proximal interphalangeal joint or closed manipulation. METHODS: seventeen patients (27 feet) who underwent forefoot reconstruction surgery by means of arthrodesis of the first metatarsophalangeal joint, resection of the heads of the lateral metatarsals and correction of the deformities of the smaller toes, were studied retrospectively. The mean follow-up was 68 months (12-148 months); the mean age was 52 years (range: 20-75 months); and four patients were male and 13 were female. RESULTS: the results were classified as excellent in 17 feet, good in two, fair in four and poor in two. The mean score on the AOFAS scale was 70 points; 21 feet (78%) were found to be asymptomatic; and six feet (22%) presented some type of symptom. Three feet presented pseudarthrosis, and one of these successfully underwent revision of the arthrodesis. There was no significant difference in scoring on the AOFAS scale or in the consolidation rate, between using a plate and screws and using Kirschner wires for fixation of the arthrodesis. CONCLUSION: arthrodesis of the first metatarsophalangeal joint with resection arthroplasty on the heads of the lateral metatarsals and correction of the deformities of the smaller toes, which was used in forefoot reconstruction in rheumatoid patients, showed good long-term results with a high satisfaction rate among the patients and clinical-functional improvement...

OBJETIVO: avaliar os resultados em longo prazo da reconstrução do antepé nos pacientes com artrite reumatoide submetidos à artrodese da articulação metatarsofalângica (MTF) do hálux, artroplastia de ressecção das cabeças dos metatarsos laterais e correção das deformidades nos dedos menores por meio de artrodese da articulação interfalângica proximal (IFP) ou manipulação fechada. MÉTODOS: foram estudados retrospectivamente 17 pacientes (27 pés) submetidos à cirurgia de reconstrução do antepé com artrodese da primeira articulação MTF, ressecção das cabeças dos metatarsos laterais e correção das deformidades nos dedos menores. O seguimento médio foi de 68 meses (12 a 148), a média de idade foi de 52 anos (20 a 75 meses) e quatro pacientes eram do sexo masculino e 13 do feminino. RESULTADOS: os resultados foram classificados como excelente em 17 pés, bom em dois, regular em quatro e ruim em dois. A pontuação média da escala Aofas (American Orthopaedic Foot and Ankle Society) foi de 70 pontos, 21 pés (78%) encontravam-se assintomáticos e seis (22%) apresentavam algum tipo de sintoma. Três pés apresentaram pseudoartrose. Um deles foi submetido à revisão da artrodese com sucesso. Não houve diferença significativa na pontuação da escala Aofas e nos índices de consolidação com o uso de placa e parafusos ou fios de Kirschner na fixação da artrodese. CONCLUSÃO: a artrodese da primeira articulação MTF com artroplastia de ressecção das cabeças dos metatarsos laterais e correção das deformidades nos dedos menores, usada na reconstrução do antepé dos pacientes reumatoides, demonstrou bons resultados em longo prazo, com elevado...

Clinical and functional evaluation of forefoot reconstruction in patients with rheumatoid arthritis.

OBJECTIVE: to evaluate the long-term results from reconstruction of the forefoot in patients with rheumatoid arthritis who underwent arthrodesis of the metatarsophalangeal joint of the hallux, resection arthroplasty of the heads of the lateral metatarsals and correction of the deformities of the smaller toes through arthrodesis of the proximal interphalangeal joint or closed manipulation. METHODS: seventeen patients (27 feet) who underwent forefoot reconstruction surgery by means of arthrodesis of the first metatarsophalangeal joint, resection of the heads of the lateral metatarsals and correction of the deformities of the smaller toes, were studied retrospectively. The mean follow-up was 68 months (12-148 months); the mean age was 52 years (range: 20-75 months); and four patients were male and 13 were female. RESULTS: the results were classified as excellent in 17 feet, good in two, fair in four and poor in two. The mean score on the AOFAS scale was 70 points; 21 feet (78%) were found to be asymptomatic; and six feet (22%) presented some type of symptom. Three feet presented pseudarthrosis, and one of these successfully underwent revision of the arthrodesis. There was no significant difference in scoring on the AOFAS scale or in the consolidation rate, between using a plate and screws and using Kirschner wires for fixation of the arthrodesis. CONCLUSION: arthrodesis of the first metatarsophalangeal joint with resection arthroplasty on the heads of the lateral metatarsals and correction of the deformities of the smaller toes, which was used in forefoot reconstruction in rheumatoid patients, showed good long-term results with a high satisfaction rate among the patients and clinical-functional improvement.

OBJETIVO: avaliar os resultados em longo prazo da reconstrução do antepé nos pacientes com artrite reumatoide submetidos à artrodese da articulação metatarsofalângica (MTF) do hálux, artroplastia de ressecção das cabeças dos metatarsos laterais e correção das deformidades nos dedos menores por meio de artrodese da articulação interfalângica proximal (IFP) ou manipulação fechada. MÉTODOS: foram estudados retrospectivamente 17 pacientes (27 pés) submetidos à cirurgia de reconstrução do antepé com artrodese da primeira articulação MTF, ressecção das cabeças dos metatarsos laterais e correção das deformidades nos dedos menores. O seguimento médio foi de 68 meses (12 a 148), a média de idade foi de 52 anos (20 a 75 meses) e quatro pacientes eram do sexo masculino e 13 do feminino. RESULTADOS: os resultados foram classificados como excelente em 17 pés, bom em dois, regular em quatro e ruim em dois. A pontuação média da escala Aofas (American Orthopaedic Foot and Ankle Society) foi de 70 pontos, 21 pés (78%) encontravam-se assintomáticos e seis (22%) apresentavam algum tipo de sintoma. Três pés apresentaram pseudoartrose. Um deles foi submetido à revisão da artrodese com sucesso. Não houve diferença significativa na pontuação da escala Aofas e nos índices de consolidação com o uso de placa e parafusos ou fios de Kirschner na fixação da artrodese. CONCLUSÃO: a artrodese da primeira articulação MTF com artroplastia de ressecção das cabeças dos metatarsos laterais e correção das deformidades nos dedos menores, usada na reconstrução do antepé dos pacientes reumatoides, demonstrou bons resultados em longo prazo, com elevado índice de satisfação dos pacientes e melhoria clínico-funcional.

Artropatia de charcot do mediopé no paciente diabético: complicação de uma doença epidêmica / Mid-foot charcot arthropathy in diabetic patients: complication of an epidemic disease

OBJETIVOS: Traçar o perfil epidemiológico dos pacientes diabéticos portadores de artropatia de Charcot acometendo exclusivamente o mediopé ou estendendo-se do mediopé ao retropé. Avaliar, a médio prazo, o resultado do tratamento a que esses pacientes são submetidos seguindo um protocolo preestabelecido. MÉTODOS: Avaliamos, retrospectivamente, 88 pacientes (110 extremidades) portadores de artropatia de Charcot do mediopé, com seguimento mínimo de 12 meses. Incluímos os pacientes portadores de artropatia de Charcot acometendo as articulações tarsometatársicas, 45 pacientes (51%); as articulações talonavicular, calcaneocuboide e subtalar, 20 pacientes (23%); e aqueles com envolvimento do mediopé e retropé, 23 pacientes (26%), segundo Brodsky e Trepman. Definimos como sucesso a preservação de um pé funcional e insucesso como amputação do pé. RESULTADOS: O tratamento da artropatia de Charcot envolvendo primariamente o mediopé foram satisfatórios em 75 pacientes (85%) tratados seguindo nosso protocolo. Nos pacientes com lesões graves, acometendo tanto o mediopé quanto o retropé, foi necessário maior número de cirurgias complexas do tipo artrodese para se obter o mesmo índice global de resultados satisfatórios. A lesão osteoarticular originada no mediopé provavelmente estende-se progressivamente ao retropé devido à demora no diagnóstico no início do tratamento adequado. CONCLUSÃO: Foi possível preservar uma extremidade funcional em 85% dos pacientes. Lesões graves envolvendo o mediopé e estendendo-se ao retropé necessitaram maior número de cirurgias para o tratamento.

OBJECTIVES: To outline the epidemiological profile of diabetic patients with Charcot arthropathy affecting the midfoot alone or extending from the midfoot to the hindfoot; To assess the results from the treatment that these patients undergo, according to a preestablished protocol, over the medium term. METHODS: We retrospectively evaluated 88 patients (110 extremities) with Charcot arthropathy of the midfoot. The minimum follow-up period was 12 months. We included 45 patients with Charcot arthropathy affecting the tarsal-metatarsal joints (51%); 20 patients in whom the talonavicular, calcaneocuboid and subtalar joints were affected (23%); and 23 patients in whom both the midfoot and hindfoot were affected (26%), as described by Brodsky and Trepman. We defined the treatment as successful when a functional foot was preserved; and unsuccessful when the foot was amputated. RESULTS: From treating Charcot arthropathy primarily involving the midfoot were satisfactory in the cases of 75 patients (85%) treated according to our protocol. For the patients with severe lesions affecting both the midfoot and the hindfoot, a greater number of complex operations (i.e. arthrodesis) were needed in order to obtain the same overall rate of satisfactory results. The osteoarticular lesions originating in the midfoot probably extended progressively to the hindfoot because of delayed diagnosis with inadequate early treatment. CONCLUSION: It was possible to preserve a functional extremity in 85% of the patients. Severe lesions involving the midfoot and extending to the hindfoot required a greater number of surgical procedures to treat them.

EVALUATION OF THE INTERMETATARSAL ANGLE AFTER THE ARTHRODESIS OF THE FIRST METATARSOPHALANGEAL JOINT FOR TREATMENT OF THE HALLUX VALGUS.

OBJECTIVE: To evaluate the correction of the intermetatarsal angle after arthrodesis of the metatarsophalangeal joint of the hallux. We believe that varus deformity of the first metatarsal can be corrected after arthrodesis of the first metatarsophalangeal joint, without the need for proximal osteotomy. METHODS: Forty-three feet of patients who had undergone arthrodesis of the first metatarsophalangeal joint between May 1997 and October 2009 were retrospectively analyzed by means of radiographs. The mean length of follow-up was 58 months. Measurements on the metatarsophalangeal angle, intermetatarsal angle and sesamoid dislocation were made using radiographs made before, immediately after and later on after the operation. RESULTS: The mean metatarsophalangeal angle was 37.6 degrees preoperatively, 12.8 degrees immediately after the operation and 16.4 degrees later on after the operation. The mean intermetatarsal angle was 16 degrees preoperatively, 10 degrees immediately after the operation and 10.2 degrees later on after the operation. Regarding sesamoid dislocation, preoperative radiographs showed most feet to be classified as G3; immediately after the operation, most were classified as G2; and later on after the operation, most were G1. CONCLUSION: The intermetatarsal angle and sesamoid dislocation improved with arthrodesis of the first metatarsophalangeal joint, without the need for osteotomy at the base of the first metatarsal.

MIDFOOT CHARCOT ARTHROPATHY IN DIABETIC PATIENTS: COMPLICATION OF AN EPIDEMIC DISEASE.

OBJECTIVES: To outline the epidemiological profile of diabetic patients with Charcot arthropathy affecting the midfoot alone or extending from the midfoot to the hindfoot; To assess the results from the treatment that these patients undergo, according to a preestablished protocol, over the medium term. METHODS: We retrospectively evaluated 88 patients (110 extremities) with Charcot arthropathy of the midfoot. The minimum follow-up period was 12 months. We included 45 patients with Charcot arthropathy affecting the tarsal-metatarsal joints (51%); 20 patients in whom the talonavicular, calcaneocuboid and subtalar joints were affected (23%); and 23 patients in whom both the midfoot and hindfoot were affected (26%), as described by Brodsky and Trepman. We defined the treatment as successful when a functional foot was preserved; and unsuccessful when the foot was amputated. RESULTS: From treating Charcot arthropathy primarily involving the midfoot were satisfactory in the cases of 75 patients (85%) treated according to our protocol. For the patients with severe lesions affecting both the midfoot and the hindfoot, a greater number of complex operations (i.e. arthrodesis) were needed in order to obtain the same overall rate of satisfactory results. The osteoarticular lesions originating in the midfoot probably extended progressively to the hindfoot because of delayed diagnosis with inadequate early treatment. CONCLUSION: It was possible to preserve a functional extremity in 85% of the patients. Severe lesions involving the midfoot and extending to the hindfoot required a greater number of surgical procedures to treat them.

Avaliação do ângulo intermetatarsal após a artrodese da primeira articulação metatarsofalangeana para tratamento do hálux valgo / Evaluation of the intermetatarsal angle after the arthrodesis of the first metatarsophalangeal joint for treatment of the hallux valgus

OBJETIVO: Avaliar a correção do ângulo intermetatarsal após a artrodese da articulação metatarsofalangeana do hálux. Acreditamos que a deformidade em varo do primeiro metatarso pode ser corrigida após a artrodese da primeira articulação metatarsofalangeana, sem a necessidade da osteotomia proximal. MÉTODO: Foram analisados, retrospectivamente, 43 pés de pacientes submetidos à artrodese da primeira articulação metatarsofalangeana no período de maio de 1997 a outubro de 2009 utilizando radiografias. O tempo médio de seguimento foi de 58 meses. A mensuração dos ângulos metatarsofalangeano, intermetatarsal e a luxação dos sesamoides foram realizadas nas radiografias no pré-operatório, pós-operatório imediato e pós-operatório tardio. RESULTADOS: O ângulo médio metatarsofalangeano foi de 37,6 graus no pré-operatório, 12,8 graus no pós-operatório imediato e 16,4 graus no pósoperatório tardio. O ângulo médio intermetatarsal foi de 16 graus no pré-operatório, 10 graus no pós-operatório imediato e 10,2 graus no pós-operatório tardio. Quanto à luxação dos sesamoides, nas radiografias pré-operatórias a maioria dos pés foram classificados como G3, no pós-operatório imediato foi classificada como G2 e no pós-operatório tardio como G1. CONCLUSÃO: O ângulo intermetatarsal e a luxação dos sesamoides melhoram com a artrodese da primeira articulação metatarsofalangeana sem a necessidade de uma osteotomia na base do primeiro metatarso.

OBJECTIVE: To evaluate the correction of the intermetatarsal angle after arthrodesis of the metatarsophalangeal joint of the hallux. We believe that varus deformity of the first metatarsal can be corrected after arthrodesis of the first metatarsophalangeal joint, without the need for proximal osteotomy. METHODS: Forty-three feet of patients who had undergone arthrodesis of the first metatarsophalangeal joint between May 1997 and October 2009 were retrospectively analyzed by means of radiographs. The mean length of followup was 58 months. Measurements on the metatarsophalangeal angle, intermetatarsal angle and sesamoid dislocation were made using radiographs made before, immediately after and later on after the operation. RESULTS: The mean metatarsophalangeal angle was 37.6 degrees preoperatively, 12.8 degrees immediately after the operation and 16.4 degrees later on after the operation. The mean intermetatarsal angle was 16 degrees preoperatively, 10 degrees immediately after the operation and 10.2 degrees later on after the operation. Regarding sesamoid dislocation, preoperative radiographs showed most feet to be classified as G3; immediately after the operation, most were classified as G2; and later on after the operation, most were G1. CONCLUSION: The intermetatarsal angle and sesamoid dislocation improved with arthrodesis of the first metatarsophalangeal joint, without the need for osteotomy at the base of the first metatarsal.

Lesões agudas do tendão do calcâneo / Acute lesions of Achiles tendon

Objetivo: Apresentar o resultado do tratamento das lesões agudas do tendão do calcâneo tratadas no Grupo do Pé e Tornozelo da Santa Casa de Misericórdia de São Paulo e suas complicações. Casuística e métodos: Reavaliamos 14 pacientes, 11 do sexo masculino e 3 do feminino, com média idade de 35 anos. O tempo médio de seguimento foi de 63 meses. Avaliamos a amplitude de movimento do tornozelo e retropé, a hipotrofia da musculatura da perna, a força do tendão do calcâneo, a altura máxima atingida pelo calcâneo em relação ao solo e a capacidade de pular sobre o pé lesionado. Avaliamos também satisfação com o resultado obtido e a pontuação obtida na escala da ?American Orthopaedic Foot and Ankle Society? ? AOFAS ? para o retropé. Resultados: Houve uma perda média de 4,8° na flexão plantar do tornozelo. Apresentavam hipotrofia muscular da perna sete pacientes, com perda média de 2,1 cm. Todos tinham grau V de força muscular e nenhum mostrava déficit na deambulação na ponta dos pés. A altura máxima entre o calcâneo e o solo no lado lesado foi de 8,5 cm em média e no lado contralateral foi de 9,2 cm. Dos pacientes, 92% apresentaram um resultado excelente na avaliação da capacidade de pular sobre o pé lesionado em apoio monopodal. Nos pacientes tratados cirurgicamente, encontramos cinco casos com complicações (35,7%). Todos estavam completamente satisfeitos com o resultado do tratamento e nenhum tinha incapacidade funcional no momento da reavaliação. Todos retornaram aos mesmos níveis de atividades laborativas de antes da lesão, sendo que 58,3% retornaram aos mesmos níveis de atividades esportivas de antes da lesão. A média do escore AOFAS para o retropé foi de 98 pontos. Conclusão: O número de complicações nos pacientes tratados pelo método cirúrgico foi elevado. No entanto, estes pacientes apresentaram bons resultados clínico-funcionais, assim como aqueles tratados pelo método conservador. Acreditamos que a controvérsia quanto ao melhor método permaneça, e novos estudos prospectivos e randomizados sejam necessários para elucidar esta questão.

Correção do hálux valgo leve ou moderado utilizando as osteotomias de Akin e em chevron combinadas / Correction of mild or moderate hallux valgus deformity using Akin and chevron osteotomies combined

Objetivo: Analisar os resultados clínico-funcionais do tratamento da deformidade leve ou moderada do hálux valgo, utilizando a osteotomia de Akin e a osteotomia em chevron combinadas. Casuística e métodos: Foram estudados 29 pacientes, totalizando 47 pés, com um tempo médio de segmento de 60 meses. Foram utilizados parâmetros clínicos e radiográficos para avaliação. Excluímos pacientes com tempo de seguimento pós-operatório inferior a um ano, com hálux valgo grave, com alterações degenerativas da articulação metatarsofalangeana do hálux na radiografia pré-operatória e aqueles com diagnóstico de artrite reumatoide. Resultados: Observamos que 74,5% dos pacientes ficaram completamente satisfeitos em relação ao alívio da dor, em relação à aparência estética obtivemos 91,5% de satisfação e 96,6% dos pacientes retornaram as atividades funcionais que desempenhavam antes do procedimento cirúrgico até o terceiro mês de pós-operatório. Não notamos rigidez articular pós-operatória. Houve uma melhora da média do ângulo intermetatarsal de 3,6º (12,4º no pré-operatório para 8,8º no pós-operatório) e uma média de correção do ângulo de hálux valgo de 12º (25º no pré-operatório para 13º no pós-operatório). Não obtivemos nenhum caso de necrose avascular. Conclusão: A combinação das osteotomias de Akin e em chevron para a correção das deformidades leves e moderadas do hálux valgo se mostrou satisfatória tanto na avaliação clínica como na radiográfica.

ANALYSIS OF CLINICAL AND FUNCTIONAL OUTCOME AND COMPLICATIONS OF TALAR NECK FRACTURES.

OBJECTIVE: To evaluate the clinical, functional and radiographic results from talar neck fractures in patients treated at the Foot and Ankle Surgery Group of Santa Casa de Sao Paulo. METHOD: We evaluated 20 patients. The mean follow-up time was 71 months. One fracture was classified as Hawkins Type I, 12 as Hawkins type II, five as Hawkins type III, two as Hawkins type IV and four fractures were open. RESULTS: One patient was treated conservatively, 16 were treated with open reduction and internal fixation (three with primary subtalar arthrodesis), one was treated with talectomy and two with tibiotalocalcaneal arthrodesis. The reduction obtained was anatomical in seven feet, acceptable in six feet and poor in four. Seven patients had early complications. There was one case of delayed consolidation and four of talar body osteonecrosis. Four patients required secondary reconstruction procedures. No significant radiographic impairment of the ankle joint was found in 62% of the patients and of the subtalar joint in 25%. Of the patients who did not undergo secondary procedures, 81% complained about the treated foot, 37.5% showed some deformity, 44% presented diminished sensitivity and 50% had to retire from work. The mean loss of motion in the ankle was 49%, and in the subtalar joint, 80%. The average AOFAS score was 73 points. CONCLUSION: Talar neck fractures are associated with high rates of clinical, functional and radiographic complications.

Análise do resultado clínico-funcional e das complicações da fratura do colo do tálus / Analysis of clinical and functional outcome and complications of talar neck fractures

OBJETIVO: Avaliar o resultado clínico-funcional e radiográfico dos pacientes com fraturas do colo do tálus tratados pelo Grupo de Cirurgia do Pé e Tornozelo da Santa Casa de São Paulo. MÉTODO: Avaliamos 20 pacientes, com tempo médio de seguimento de 71 meses: um com fratura do tipo I, 12 do tipo II, cinco do tipo III e dois do tipo IV, sendo quatro fraturas expostas. RESULTADOS: Um paciente foi tratado incruentamente, 16 com RAFI (três com artrodese subtalar primária), um com talectomia e dois com artrodese tibiotalocalcaneana. A redução obtida foi classificada como anatômica em sete pés, aceitável em seis, e ruim em quatro. Sete pacientes apresentaram complicações precoces. Houve um retardo de consolidação e quatro osteonecroses do corpo do tálus. Quatro pacientes necessitaram de procedimentos reconstrutivos secundários. Sessenta e dois porcento dos pacientes não apresentaram comprometimento radiográfico importante na articulação do tornozelo e 25 por cento na articulação subtalar. Dos pacientes não submetidos a procedimentos secundários, 81 por cento apresentaram queixas referentes ao pé tratado, 37,5 por cento apresentaram alguma deformidade, 44 por cento déficit sensitivo e 50 por cento estavam aposentados. A perda média de movimento do tornozelo foi de 49 por cento e da subtalar 80 por cento. A pontuação média pela escala AOFAS foi de 73 pontos. CONCLUSÃO: A fratura do colo do tálus leva a alta incidência de complicações clínico-funcionais e radiográficas.

OBJETIVE: To evaluate the clinical, functional and radiographic outcomes of talar neck fractures in patients treated at the Foot and Ankle Surgery Group of the Santa Casa de São Paulo. METHOD: 20 patients were evaluated. Mean follow-up time was 71 months. One fracture was classified as Hawkins Type I, 12 as Hawkins type II, five as Hawkins type III, two as Hawkins type IV, and four fractures were open. RESULTS: One patient was treated conservatively, 16 were treated with ORIF (three with primary subtalar arthrodesis), one treated with talectomy and two with tibiotalocalcaneal arthrodesis. The reduction was anatomical in seven feet, acceptable in six feet and poor in four. Seven patients had early complications. There was one delay of consolidation and four talar body osteonecrosis. No signs or minimal signs of radiographic arthritis of the affected ankles were found in 62 percent of the patients and 25 percent of affected subtalar joints. Of the 16 patients who did not require secondary procedures, 81 percent complained about the treated foot, 37.5 percent showed some deformity, 44 percent had decreased skin sensitivity and 50 percent never returned to work. The mean loss of motion in the ankle was 49 percent, and in the subtalar joint, 80 percent. The average AOFAS score was 73 points. CONCLUSION: Talar neck fractures are associated with high rates of clinical, functional and radiographic complications.

Aspectos epidemiológicos das lesões no pé e tornozelo do paciente diabético / Epidemiological aspects of foot and ankle injury in the diabetic patient

OBJETIVO: Identificar o perfil epidemiológico dos pacientes que procuram tratamento ortopédico das complicações nos pés e tornozelos relacionadas ao diabetes, além de correlacionar à sequência de eventos que culminam na amputação da extremidade. MÉTODO: analisamos os dados de prontuário de 300 pacientes no período compreendido entre março de 1997 a julho de 2006. RESULTADOS: A média de idade foi 61 anos, destes, duzentos e setenta e três pacientes (91 por cento) apresentavam diagnóstico de diabetes do tipo II, onde somente 49 (16,3 por cento) faziam controle regular da glicemia. Quatrocentos e cinco extremidades apresentavam problemas afetando a função do pé ou tornozelo, detacando-se: 102 extremidades (34 por cento) com lesões osteoarticulares relacionadas a neuroartropatia de Charcot; 181 extremidades (60,4 por cento) com ulceração crônica e 97 extremidades (32,4 por cento) com infecção. Após tempo médio de seguimento 14 pacientes (4,6 por cento) foram a óbito. CONCLUSÃO: A ulceração na planta dos pés foi a complicação mais frequente na nossa série de pacientes que, estavam na sétima década de vida, apresentavam diabetes do tipo II, faziam uso irregular de insulina e não realizavam controle adequado da glicemia. A perda da sensibilidade protetora nos pés, em associação com deformidade pré-existente, foi identificada como a principal causa das infecções secundárias culminando com a amputação da extremidade.

OBJECTIVE: To identify the epidemiological profile of patients undergoing orthopedic treatment for complications of the feet and ankles due to diabetes, and to try to establish the sequence of events that led to amputation of the limb. METHOD: The medical records of 300 diabetic patients treated from March, 1997 to July, 2006 were systematically reviewed. RESULTS: The mean age of the patients was 61 years. Of these, two hundred and seventy three (91 percent) were diagnosed with type II diabetes, but only 49 (16.3 percent) had proper medical supervision and control of their glycemia levels. Problems affecting the function of the foot and ankle were found in 405 limbs, with: 102 osteoarticular deformities associated with Charcot's neuroarthropathy (34 percent); 181 chronic ulcers (60.4 percent); and 97 infected limbs (32.4 percent). After the average follow-up time, 14 patients (4.6 percent) died. CONCLUSION: Ulceration of the sole of the foot was the most common complication in our series of patients, the majority of whom were in their seventies, presented type II diabetes, were insulin dependent, and did not have adequate control of glycemia. Loss of sensitivity of the foot, associated with pre-existing deformities, were identified as the main causes of secondary infections culminating in amputation of the limb.