Avulsion Fracture of the Tibial Tuberosity in an Adolescent: Case Report.

The present study reports a rare case of avulsion fracture of the tibial tuberosity in an adolescent. A 14-year-old male patient sprained his left knee during a soccer match. At the first emergency-room visit, he presented pain in his left knee, 2 +/4+ edema, and inability to walk and flex the affected knee, but no neurovascular changes or signs of compartment syndrome. Radiographs revealed a physeal fracture at the left proximal tibia, classified by Ogden, Tross and Murphy, and modified by Ryu and Debenham, as type IV, and complemented by Aerts et al. as type IV-B. Immobilization was performed with a plaster cast from the inguinal to malleolar regions, followed by analgesia. The patient was operated on the next day, when open reduction and internal fixation using 4.5-mm cannulated screws were performed. The patient was discharged one day after surgery, with plaster cast immobilization and load restraint for four weeks, and bone consolidation was radiologically confirmed three months after the procedure. The patient evolved with a range of motion similar to that of the contralateral limb, no length discrepancy in the lower limbs, and no complaints after one year of follow-up.

Avulsion Fracture of the Tibial Tuberosity in an Adolescent: Case Report / Fratura por avulsão da tuberosidade da tíbia em adolescente: Relato de caso

Abstract The present study reports a rare case of avulsion fracture of the tibial tuberosity in an adolescent. A 14-year-old male patient sprained his left knee during a soccer match. At the first emergency-room visit, he presented pain in his left knee, 2 +/4+ edema, and inability to walk and flex the affected knee, but no neurovascular changes or signs of compartment syndrome. Radiographs revealed a physeal fracture at the left proximal tibia, classified by Ogden, Tross and Murphy, and modified by Ryu and Debenham, as type IV, and complemented by Aerts et al. as type IV-B. Immobilization was performed with a plaster cast from the inguinal to malleolar regions, followed by analgesia. The patient was operated on the next day, when open reduction and internal fixation using 4.5-mm cannulated screws were performed. The patient was discharged one day after surgery, with plaster cast immobilization and load restraint for four weeks, and bone consolidation was radiologically confirmed three months after the procedure. The patient evolved with a range of motion similar to that of the contralateral limb, no length discrepancy in the lower limbs, and no complaints after one year of follow-up.

Resumo O presente estudo tem como objetivo relatar um caso raro de fratura por avulsão da tuberosidade da tíbia em adolescente. Um paciente de 14 anos, do sexo masculino, sofreu entorse de joelho esquerdo durante partida de futebol. No primeiro atendimento em pronto-socorro, ele apresentava dor no joelho esquerdo, edema 2 +/4 + , incapacidade de deambulação e de flexo-extensão do joelho acometido, sem alterações neurovasculares ou sinais de síndrome compartimental. Nas radiografias, identificou-se fratura fisária na tíbia proximal esquerda, classificada por Ogden, Tross e Murphy, com modificação por Ryu e Debenham, como tipo IV, e complementada por Aerts et al. como tipo IV-B. Foi realizada imobilização com tala gessada inguino-maleolar e analgesia, e o paciente submetido a cirurgia no dia seguinte, com redução aberta e fixação interna utilizando parafusos canulados 4,5 mm. O paciente recebeu alta no dia seguinte à cirurgia, sendo mantida a imobilização com tala gessada e a restrição de carga por quatro semanas, e apresentou consolidação óssea confirmada por radiografia com três meses do pós-operatório. O paciente evoluiu sem discrepância de comprimento dos membros inferiores, arco de movimento igual ao do membro contralateral, e sem queixas no seguimento de um ano.

Are 2 Radiographic Views As Good as 3 Views to Diagnose Ankle Fractures in Children and Adolescents?

OBJECTIVES: Ankle radiographs are among the most commonly obtained trauma images in the pediatric population, with the standard 3 views (AP/mortise [M]/lateral [L]) routinely ordered in the emergency department. The purpose of this study was to compare the diagnostic accuracy, sensitivity, and specificity of sets of 2 views (AP/L or M/L) with the standard 3 views. METHODS: One hundred twenty sets of ankle radiographs of skeletally immature patients obtained in the emergency department of a level 1 pediatric trauma center were used. These included sets with and without fractures. Sets of 3 and 2 views were reviewed by pairs of pediatric-trained orthopedic surgeons, radiologists, and emergency physicians. Each completed 3 randomized viewing sessions where all possible combinations for each set of radiographs were reviewed. Diagnoses for the 3 sets of views were compared for accuracy, sensitivity, and specificity. RESULTS: Overall accuracy, sensitivity, and specificity for all reviewers were as follows: AP/M/L 74%, 94%, and 90%, AP/L 71%, 90%, and 94%, as well as M/L 69%, 90%, and 91%. P values for accuracy, sensitivity, and specificity of AP/L and M/L compared with 3 views were 0.34, 0.04, and 0.52, as well as 0.04, 0.004, and 1.00, respectively. CONCLUSIONS: In skeletally immature patients, statistically significant differences in accuracy were obtained when comparing the standard 3 AP/M/L views with more limited M/L views, suggesting that this set of 2 views is not as accurate. Differences in sensitivity of limited views were also statistically significant. Conversely, differences in accuracy between the standard 3 views and AP/Lateral views were not statistically significant. While more limited AP/L views may be comparable in accuracy and specificity and lead to dramatically decreased radiation and costs, this can be at the expense of less diagnostic sensitivity and increased risk of misdiagnosing or missing certain fractures. LEVEL OF EVIDENCE: Level III.

Comparison between semitendinosus transfer to distal femur and medial hamstrings surgical lengthening for treatment of flexed knee gait in cerebral palsy.

PURPOSE: Hamstrings surgical lengthening (HSL) has been frequently used for the treatment of flexed knee gait in cerebral palsy; however, recurrence of knee flexion deformity (KFD) and increase of anterior pelvic tilt (APT) were reported in a long-term follow-up. RESEARCH QUESTION: The aim of this study was to compare semitendinosus transfer to distal femur (STTX) and semitendinosus surgical lengthening (STL) regarding the reduction of KFD and the increase of APT after flexed knee gait treatment. METHODS: One hundred and eleven patients were evaluated and they were divided into two groups according to surgical procedures at knees: group A (65 patients/130 knees), including patients who received medial HSL as part of multilevel approach; group B (46 patients/92 knees), represented by patients who underwent orthopedic surgery including an STTX instead of STL. RESULTS: Fixed knee flexion deformity (FKFD) decreased only in group B (from 6.79° to 2.96°, p < 0.001) after intervention. In kinematics, APT increased from 16.38° to 19.03° in group A (p = 0.003), while group B also increased from 15.26° to 20.59° (p < 0.001). The minimum knee flexion in stance phase (MKFS) reduced from 25.34° to 21.65° (p = 0.016) in group A and from 31° to 19.57° (p < 0.001) in group B. In the comparison between groups A and B, the increase of APT (p = 0.028) and reduction of FKFD (p < 0.001), popliteal angle (p = 0.001), bilateral popliteal angle (p = 0.003) and MKFS (p = 0.006) were higher after STTX than STL. CONCLUSION: In the present study, patients who received STTX exhibited more improvement of knee extension at clinical examination and during gait than those who underwent to STL; however, STTX was not effective to prevent the increase of APT after flexed knee gait treatment.

The effect of the Majestro-Frost procedure on internal hip rotation during gait in patients with cerebral palsy.

BACKGROUND: Muscle imbalance is related to persistent internal hip rotation (IHR) after femoral derotation osteotomy (FDO) in cerebral palsy (CP). The aim of this study was to evaluate the effect of the Majestro-Frost soft tissue procedure (MFP), which potentially addresses muscle imbalance, on IHR in CP patients during walking. METHODS: A retrospective study of an existing database (medical records and gait laboratory data) was conducted and a search was performed using the following inclusion criteria: (1) diagnosis of spastic CP, (2) GMFCS levels I-III; (3) mean IHR during stance phase higher than 11° at baseline; (4) individuals who received single event multilevel orthopedic surgery in the lower limbs and had three-dimensional gait analyses (3DGA) before and after the intervention. Patients who underwent a FDO were excluded. Eighty-three individuals were considered for the study and they were divided into two groups: No MFP (45 patients who did not receive a MFP) and MFP (36 patients who underwent a MFP). A full clinical examination and 3DGA, with kinematics calculated according to a standard software procedure (Plugin Gait), were performed before and after the intervention, and the results were compared. RESULTS: The studied groups matched regarding demographic data and GMFCS distribution. The mean follow-up time was more than 20 months on both groups. The increase of clinical external hip rotation (EHR) on physical examination was observed only in the MFP group (from 26.4° to 33°, p = 0.002). During gait analysis, IHR decreased from 21.2° to 4.5° in the MFP group (p < 0.001) and from 16.9° to 7.9° in the No MFP group (p < 0.001). The reduction of IHR during gait was more significant in the MFP group (p = 0.001). SIGNIFICANCE: In the present study, patients who underwent a MFP showed more reduction of IHR during gait than those which did not undergo a MFP.

The increase of anterior pelvic tilt after crouch gait treatment in patients with cerebral palsy.

BACKGROUND: The increase of anterior pelvic tilt (APT) has been described after the treatment of crouch gait in cerebral palsy (CP). The ideal treatment option for flexed knee gait in CP should provide knee extension improvement in the stance phase without generating the increase of APT. RESEARCH QUESTION: The purpose of this study was to compare three different approaches used for the treatment of crouch gait in CP [distal femur extension osteotomy (DFEO), patellar tendon shortening (PTS) and the combination of DFEO +PTS] regarding the increase of APT after the interventions. METHODS: The inclusion criteria were: (1) diagnosis of spastic diplegic CP, (2) GMFCS levels I-III, (3) patients who underwent DFEO and/or PTS and (4) with complete documentation in the gait laboratory before and after the intervention. The included patients were divided into 3 groups, according to the procedures performed for crouch gait treatment: PTS (19 patients), DFEO (54 patients) and PTS + DFEO (22 patients). RESULTS: During stance phase, knee flexion decreased from 41.60 to 13.60 in the PTS group (p < 0.001), from 46.00 to 30.70 in the DFEO group (p < 0.001) and from 52.30 to 29.50 in the PTS + DFEO group (p < 0.001). APT increased 140 (p < 0.001) in the PTS group, 7.1° (p < 0.001) in the DFEO group and 6.60 (p < 0.001) in the PTS + DFEO group after surgical intervention. The PTS group presented a more significant deterioration of pelvic tilt than the DFEO (p = 0.002) and PTS + DFEO (p = 0.001) groups. The increase of APT was higher when HSL was also performed in the PTS + DFEO group (p = 0.016). SIGNIFICANCE: The increase of APT was observed in all studied groups, but it was more significant for those who underwent a PTS. The inclusion of HSL in the surgical plan was related a higher increase of APT in the PTS + DFEO group.

Correlation between physical examination and three-dimensional gait analysis in the assessment of rotational abnormalities in children with cerebral palsy.

Objective To evaluate the correlation between physical examination data concerning hip rotation and tibial torsion with transverse plane kinematics in children with cerebral palsy; and to determine which time points and events of the gait cycle present higher correlation with physical examination findings. Methods A total of 195 children with cerebral palsy seen at two gait laboratories from 2008 and 2016 were included in this study. Physical examination measurements included internal hip rotation, external hip rotation, mid-point hip rotation and the transmalleolar axis angle. Six kinematic parameters were selected for each segment to assess hip rotation and shank-based foot rotation. Correlations between physical examination and kinematic measures were analyzed by Spearman correlation coefficients, and a significance level of 5% was considered. Results Comparing physical examination measurements of hip rotation and hip kinematics, we found moderate to strong correlations for all variables (p<0.001). The highest coefficients were seen between the mid-point hip rotation on physical examination and hip rotation kinematics (rho range: 0.48-0.61). Moderate correlations were also found between the transmalleolar axis angle measurement on physical examination and foot rotation kinematics (rho range 0.44-0.56; p<0.001). Conclusion These findings may have clinical implications in the assessment and management of transverse plane gait deviations in children with cerebral palsy.

Correlation between physical examination and three-dimensional gait analysis in the assessment of rotational abnormalities in children with cerebral palsy / Correlação entre exame físico e análise tridimensional da marcha na determinação dos desvios rotacionais em crianças com paralisia cerebral

Abstract Objective To evaluate the correlation between physical examination data concerning hip rotation and tibial torsion with transverse plane kinematics in children with cerebral palsy; and to determine which time points and events of the gait cycle present higher correlation with physical examination findings. Methods A total of 195 children with cerebral palsy seen at two gait laboratories from 2008 and 2016 were included in this study. Physical examination measurements included internal hip rotation, external hip rotation, mid-point hip rotation and the transmalleolar axis angle. Six kinematic parameters were selected for each segment to assess hip rotation and shank-based foot rotation. Correlations between physical examination and kinematic measures were analyzed by Spearman correlation coefficients, and a significance level of 5% was considered. Results Comparing physical examination measurements of hip rotation and hip kinematics, we found moderate to strong correlations for all variables (p<0.001). The highest coefficients were seen between the mid-point hip rotation on physical examination and hip rotation kinematics (rho range: 0.48-0.61). Moderate correlations were also found between the transmalleolar axis angle measurement on physical examination and foot rotation kinematics (rho range 0.44-0.56; p<0.001). Conclusion These findings may have clinical implications in the assessment and management of transverse plane gait deviations in children with cerebral palsy.

Resumo Objetivo Avaliar a correlação entre dados do exame físico relativos à rotação do quadril e torção tibial com a cinemática do plano transverso em crianças com paralisia cerebral; e determinar quais pontos no tempo e eventos do ciclo de marcha apresentam maior correlação com achados do exame físico. Métodos Um total de 195 crianças com paralisia cerebral vistas em dois laboratórios de marcha, de 2008 a 2016, foi incluído neste estudo. As medidas do exame físico incluíram rotação interna do quadril, rotação externa do quadril, ponto médio da rotação do quadril e ângulo do eixo transmaleolar. Foram selecionados seis parâmetros cinemáticos para cada segmento, para avaliar a rotação do quadril e a do pé em relação à perna durante a marcha. As correlações entre exame físico e medidas cinemáticas foram analisadas por coeficientes de correlação de Spearman, e considerou-se um nível de significância de 5%. Resultados Comparando as medidas da rotação do quadril e da cinemática do quadril, encontramos correlações moderadas a fortes para todas as variáveis (p<0,001). Os coeficientes mais altos foram observados entre o ponto médio da rotação do quadril no exame físico e a rotação do quadril na cinemática (rho range: 0,48-0,61). Correlações moderadas também foram encontradas entre a medição do ângulo do eixo transmaleolar no exame físico e a rotação do pé em relação à perna na cinemática (faixa rho: 0,44-0,56; p<0,001). Conclusão Estes achados podem ter implicações clínicas na avaliação e no tratamento de desvios da marcha do plano transverso em crianças com paralisia cerebral.

DOES RECTUS FEMORIS TRANSFER INCREASE KNEE FLEXION DURING STANCE PHASE IN CEREBRAL PALSY?

OBJECTIVE: To evaluate whether distal rectus femoris transfer (DRFT) is related to postoperative increase of knee flexion during the stance phase in cerebral palsy (CP). METHODS: The inclusion criteria were Gross Motor Function Classification System (GMFCS) levels I-III, kinematic criteria for stiff-knee gait at baseline, and individuals who underwent orthopaedic surgery and had gait analyses performed before and after intervention. The patients included were divided into the following two groups: NO-DRFT (133 patients), which included patients who underwent orthopaedic surgery without DRFT, and DRFT (83 patients), which included patients who underwent orthopaedic surgery that included DRFT. The primary outcome was to evaluate in each group if minimum knee flexion in stance phase (FMJFA) changed after treatment. RESULTS: The mean FMJFA increased from 13.19° to 16.74° (p=0.003) and from 10.60° to 14.80° (p=0.001) in Groups NO-DRFT and DRFT, respectively. The post-operative FMJFA was similar between groups NO-DRFT and DRFT (p=0.534). The increase of FMJFA during the second exam (from 13.01° to 22.51°) was higher among the GMFCS III patients in the DRFT group (p<0.001). CONCLUSION: In this study, DRFT did not generate additional increase of knee flexion during stance phase when compared to the control group. Level of Evidence III, Retrospective Comparative Study.

DOES RECTUS FEMORIS TRANSFER INCREASE KNEE FLEXION DURING STANCE PHASE IN CEREBRAL PALSY?

ABSTRACT Objective: To evaluate whether distal rectus femoris transfer (DRFT) is related to postoperative increase of knee flexion during the stance phase in cerebral palsy (CP). Methods: The inclusion criteria were Gross Motor Function Classification System (GMFCS) levels I-III, kinematic criteria for stiff-knee gait at baseline, and individuals who underwent orthopaedic surgery and had gait analyses performed before and after intervention. The patients included were divided into the following two groups: NO-DRFT (133 patients), which included patients who underwent orthopaedic surgery without DRFT, and DRFT (83 patients), which included patients who underwent orthopaedic surgery that included DRFT. The primary outcome was to evaluate in each group if minimum knee flexion in stance phase (FMJFA) changed after treatment. Results: The mean FMJFA increased from 13.19° to 16.74° (p=0.003) and from 10.60° to 14.80° (p=0.001) in Groups NO-DRFT and DRFT, respectively. The post-operative FMJFA was similar between groups NO-DRFT and DRFT (p=0.534). The increase of FMJFA during the second exam (from 13.01° to 22.51°) was higher among the GMFCS III patients in the DRFT group (p<0.001). Conclusion: In this study, DRFT did not generate additional increase of knee flexion during stance phase when compared to the control group. Level of Evidence III, Retrospective Comparative Study.

Intra and interobserver concordance of the AO classification system for fractures of the long bones in the pediatric population.

OBJECTIVE: The AO classification for fractures of the long bones in the pediatric population was developed and validated in 2006. However, the complexity of this system has limited its use in clinical practice and few studies in the literature have evaluated its reproducibility and applicability. The present study had the objective of determining the intra and interobserver agreement using the pediatric AO system, among physicians with different levels of experience. METHODS: After making the sample calculation, 108 consecutive radiographs on long-bone fractures in patients aged 0-16 years, coming from the digital files of the quaternary-level hospital, were selected. The radiographs were classified by five examiners with different levels of experience after prior explanations about the system. A chart containing images from the classification was made available for consultation. The evaluations were made at two different times by each observer. The Fleiss kappa index was used to ascertain the intra and interobserver agreement. RESULTS: Intraobserver agreement that was at least substantial was obtained for all the items of the classification and it reached excellent levels for all observers in relation to five of the seven items considered. The interobserver evaluation presented excellent levels of agreement in two items, substantial in two items, moderate to substantial in one item and poor to moderate in one item. No influence from the observer's experience was observed with regard to obtaining higher or lower levels of agreement, either in the intraobserver or in the interobserver evaluation. CONCLUSIONS: In this study, the intra and interobserver agreement was considered to be good or excellent for the pediatric AO classification system, for the parameters of bone, segment, paired bone, subsegment, standard and deviation. However, the intra and interobserver agreement was statistically unsatisfactory for the parameter of severity/side of avulsion. The levels of agreement obtained did not depend on the observer's level of experience within pediatric orthopedics.

OBJETIVO: A classificação AO para fraturas dos ossos longos na população pediátrica foi desenvolvida e validada em 2006. Entretanto, a complexidade desse sistema tem limitado o seu uso na prática clínica. Poucos estudos na literatura avaliam sua reprodutibilidade e aplicabilidade. Este trabalho teve como objetivo determinar a concordância intra e interobservadores com o uso do sistema de classificação AO pediátrica entre médicos de diferentes níveis de experiência. MÉTODOS: Após a feitura do cálculo amostral, foram selecionadas 108 radiografias consecutivas de fraturas de ossos longos de pacientes de 0­16 anos, provenientes do arquivo digital de um hospital de nível quaternário. As radiografias foram classificadas por cinco examinadores com diferentes níveis de experiência após uma explicação prévia sobre o sistema. Foi mostrada uma planilha que continha as imagens da classificação para consulta. As avaliações foram feitas em dois momentos distintos por cada observador. O índice Kappa de Fleiss foi usado para verificar a concordância intra e interobservadores. RESULTADOS: Foram obtidas concordâncias intraobservadores no mínimo substanciais em todos os itens da classificação, alcançaram níveis excelentes por todos os observadores em cinco dos sete itens considerados. A avaliação interobservadores apresentou níveis de concordância excelentes em dois itens, substancial em dois itens, moderada a substancial em um item e pobre a moderada em um dos itens. Não se observou influência da experiência do observador na obtenção de maiores ou menores níveis de concordância, intra ou interobservadores. CONCLUSÕES: Neste estudo, a concordância intra e interobservadores foi considerada boa ou excelente para o sistema de classificação AO pediátrico para os parâmetros: osso, segmento, osso pareado, subsegmento, padrão e desvio. No entanto, a concordância intra e interobservadores foi estatisticamente insatisfatória no parâmetro gravidade/lado da avulsão. Os níveis de concordância obtidos independem da experiência do observador em ortopedia pediátrica.

Concordância intra e interobservadores do sistema de classificação AO para fraturas dos ossos longos na população pediátrica / Intra and interobserver concordance of the AO classification system for fractures of the long bones in the pediatric population

A classificação AO para fraturas dos ossos longos na população pediátrica foi desen volvida e validada em 2006. Entretanto, a complexidade desse sistema tem limitado o seu uso na prática clínica. Poucos estudos na literatura avaliam sua reprodutibilidade e aplicabi lidade. Este trabalho teve como objetivo determinar a concordância intra e interobservadores com o uso do sistema de classificação AO pediátrica entre médicos de diferentes níveis de experiência. Métodos: Após a feitura do cálculo amostral, foram selecionadas 108 radiografias consecuti vas de fraturas de ossos longos de pacientes de 0-16 anos, provenientes do arquivo digital de um hospital de nível quaternário. As radiografias foram classificadas por cinco examina dores com diferentes níveis de experiência após uma explicação prévia sobre o sistema. Foi mostrada uma planilha que continha as imagens da classificação para consulta. As avaliações foram feitas em dois momentos distintos por cada observador. O índice Kappa de Fleiss foi usado para verificar a concordância intra e interobservadores. Resultados: Foram obtidas concordâncias intraobservadores no mínimo substanciais em todos os itens da classificação, alcançaram níveis excelentes por todos os observadores em cinco dos sete itens considerados. A avaliação interobservadores apresentou níveis de concordância excelentes em dois itens, substancial em dois itens, moderada a substancial em um item e pobre a moderada em um dos itens. Não se observou influência da experi ência do observador na obtenção de maiores ou menores níveis de concordância, intra ou interobservadores. Conclusões: Neste estudo, a concordância intra e interobservadores foi considerada boa ou excelente para o sistema de classificação AO pediátrico para os parâmetros: osso, seg mento, osso pareado, subsegmento, padrão e desvio. No entanto, a concordância intra e interobservadores foi estatisticamente insatisfatória no parâmetro gravidade/lado da avulsão. Os níveis de concordância obtidos independem da experiência do observador em ortopedia pediátrica.

The AO classification for fractures of the long bones in the pediatric population was developed and validated in 2006. However, the complexity of this system has limited its use in clinical practice and few studies in the literature have evaluated its reproducibility and applicability. The present study had the objective of determining the intra and interobserver agreement using the pediatric AO system, among physicians with different levels of experience. METHODS: After making the sample calculation, 108 consecutive radiographs on long-bone fractures in patients aged 0-16 years, coming from the digital files of the quaternary-level hospital, were selected. The radiographs were classified by five examiners with different levels of experience after prior explanations about the system. A chart containing images from the classification was made available for consultation. The evaluations were made at two different times by each observer. The Fleiss kappa index was used to ascertain the intra and interobserver agreement. RESULTS: Intraobserver agreement that was at least substantial was obtained for all the items of the classification and it reached excellent levels for all observers in relation to five of the seven items considered. The interobserver evaluation presented excellent levels of agreement in two items, substantial in two items, moderate to substantial in one item and poor to moderate in one item. No influence from the observer's experience was observed with regard to obtaining higher or lower levels of agreement, either in the intraobserver or in the interobserver evaluation. CONCLUSIONS: In this study, the intra and interobserver agreement was considered to be good or excellent for the pediatric AO classification system, for the parameters of bone, segment, paired bone, subsegment, standard and deviation. However, the intra and interobserver agreement was statistically unsatisfactory for the parameter of severity/side of avulsion. The levels of agreement obtained did not depend on the observer's level of experience within pediatric orthopedics.

Comparison of the results from simple radiography, from before to after Salter osteotomy, in patients with Legg-Calvé-Perthes disease,

Objectives: To determine whether the clinical variables and preoperative classification of patients with Legg-Calvé-Perthes disease (LCPD) who undergo Salter osteotomy correlate with the radiographic result at the time of skeletal maturity. Methods: In this retrospective cohort study, 47 individuals with LCPD who were treated using Salter osteotomy (1984-2004) were evaluated. The patients were evaluated according to sex, skin color, side affected and age at which osteotomy was performed. The preoperative radiographs were analyzed in accordance with the classifications of Waldenstrom, Catter-all, Laredo and Herring. The radiographs obtained at the time of skeletal maturity were classified using the Stulberg method. Results: The mean age at the time of surgical treatment was 82.87 months (6.9 years). The age presented a statistically significant correlation with the Stulberg grades at skeletal maturity (p < 0.001). Patients over the age of 6.12 years tended to present less favorable results. The variables of sex, skin color and side affected did not present any statistically significant correlation with the prognosis (p = 0.425; p = 0.467; p = 0.551, respectively). Only the Laredo classification presented a statistically significant correlation with the final result given by the Stulberg classification (p = 0.001). The other classifications used (Waldenstrom, Catterall and Herring) did not present any correlation between the time at which surgery was indicated and the postoperative result. Conclusions: The age at which the patients underwent surgical treatment and the Laredo classification groups were the only variables that presented significant correlations with the Stulberg classification...

Objetivos: Determinar em pacientes com doenca de Legg-Calvé-Perthes (DLCP) submetidos à osteotomia de Salter se as variáveis clínicas e as classificacões pré-operatórias se correlacionam com o resultado radiográfico na maturidade esquelética. Métodos: Neste estudo de coorte retrospectivo foram avaliados 47 indivíduos portadores da DLCP tratados com osteotomia de Salter (1984-2004). Os pacientes foram avaliados de acordo com sexo, cor, lado acometido e idade em que foi feita a osteotomia. As radiografias pré-operatórias foram analisadas de acordo com as classificacões de Waldenstrõm, Catterall, Laredo e Herring. As radiografias obtidas na maturidade esquelética foram classificadas segundo o método de Stulberg. Resultados: A média da idade no momento do tratamento cirúrgico foi de 82,87 meses (6,9 anos). A idade apresentou correlacão estatisticamente significativa com os graus de Stulberg na maturidade esquelética (p <0,001). Pacientes acima de 6,12 anos tendem a apresentar resultados menos favoráveis. As variáveis sexo, cor e lado acometido não apresentaram correlacão estatisticamente significativa com o prognóstico (p = 0,425; p = 0,467; p = 0,551, respectivamente). Apenas a classificacão de Laredo apresentou correlacão estatisticamente significante com o resultado final dado pela classificacão de Stulberg (p = 0,001). As demais classificacões usadas, Waldenstrõm, Caterall e Herring, não apresentaram correlacão entre o momento em que foi indicada a cirurgia e o resultado pós-operatório. Conclusões: A idade em que os pacientes foram submetidos ao tratamento cirúrgico e os grupos da classificacão de Laredo foram as únicas variáveis que apresentaram correlacão significativa com a classificacão de Stulberg...

Comparison of the results from simple radiography, from before to after Salter osteotomy, in patients with Legg-Calvé-Perthes disease.

OBJECTIVES: To determine whether the clinical variables and preoperative classification of patients with Legg-Calvé-Perthes disease (LCPD) who undergo Salter osteotomy correlate with the radiographic result at the time of skeletal maturity. METHODS: In this retrospective cohort study, 47 individuals with LCPD who were treated using Salter osteotomy (1984-2004) were evaluated. The patients were evaluated according to sex, skin color, side affected and age at which osteotomy was performed. The preoperative radiographs were analyzed in accordance with the classifications of Waldenström, Catterall, Laredo and Herring. The radiographs obtained at the time of skeletal maturity were classified using the Stulberg method. RESULTS: The mean age at the time of surgical treatment was 82.87 months (6.9 years). The age presented a statistically significant correlation with the Stulberg grades at skeletal maturity (p < 0.001). Patients over the age of 6.12 years tended to present less favorable results. The variables of sex, skin color and side affected did not present any statistically significant correlation with the prognosis (p = 0.425; p = 0.467; p = 0.551, respectively). Only the Laredo classification presented a statistically significant correlation with the final result given by the Stulberg classification (p = 0.001). The other classifications used (Waldenström, Catterall and Herring) did not present any correlation between the time at which surgery was indicated and the postoperative result. CONCLUSIONS: The age at which the patients underwent surgical treatment and the Laredo classification groups were the only variables that presented significant correlations with the Stulberg classification.

OBJETIVOS: Determinar em pacientes com doença de Legg-Calvé-Perthes (DLCP) submetidos à osteotomia de Salter se as variáveis clínicas e as classificações pré-operatórias se correlacionam com o resultado radiográfico na maturidade esquelética. MÉTODOS: Neste estudo de coorte retrospectivo foram avaliados 47 indivíduos portadores da DLCP tratados com osteotomia de Salter (1984-2004). Os pacientes foram avaliados de acordo com sexo, cor, lado acometido e idade em que foi feita a osteotomia. As radiografias pré-operatórias foram analisadas de acordo com as classificações de Waldenström, Catterall, Laredo e Herring. As radiografias obtidas na maturidade esquelética foram classificadas segundo o método de Stulberg. RESULTADOS: A média da idade no momento do tratamento cirúrgico foi de 82,87 meses (6,9 anos). A idade apresentou correlação estatisticamente significativa com os graus de Stulberg na maturidade esquelética (p < 0,001). Pacientes acima de 6,12 anos tendem a apresentar resultados menos favoráveis. As variáveis sexo, cor e lado acometido não apresentaram correlação estatisticamente significativa com o prognóstico (p = 0,425; p = 0,467; p = 0,551, respectivamente). Apenas a classificação de Laredo apresentou correlação estatisticamente significante com o resultado final dado pela classificação de Stulberg (p = 0,001). As demais classificações usadas, Waldenström, Caterall e Herring, não apresentaram correlação entre o momento em que foi indicada a cirurgia e o resultado pós-operatório. CONCLUSÕES: A idade em que os pacientes foram submetidos ao tratamento cirúrgico e os grupos da classificação de Laredo foram as únicas variáveis que apresentaram correlação significativa com a classificação de Stulberg.

Programas de rastreamento de displasia de quadril em recém-nascidos / Aprenda a pronunciar Hip dysplasia screening programs in newborns

Introdução: Displasia de desenvolvimento do quadril não corrigida está associada com morbidades no longo prazo, tais como anormalidades da marcha, dor crônica e artrite degenerativa.Objetivo: Determinar o efeito de diferentes programas de rastreamento de displasia de desenvolvimento do quadril sobre a incidência, posteriormente, de luxação congênita do quadril.Métodos: Métodos de busca: Foi realizada busca nas bases Central (The Cochrane Library), Medline e Embase (janeiro de 2011), complementada por pesquisas em bases de registros de ensaios clínicos, anais de conferências, referências cruzadas e contato com especialistas.Critérios de seleção: Ensaios clínicos randomizados, quasi-randomizados ou cluster comparando a eficácia dos programas de triagem para a displasia de quadril em recém-nascidos.Coleta e análise de dados: Três autores independentes avaliaram a elegibilidade e a qualidade dos estudos, e extraíram os dados.Principais resultados: Nenhum estudo examinou o efeito do rastreamento (clínico e/ou ultrassonografia) e do tratamento precoce versus a ausência de rastreamento e o tratamento tardio.Conclusões dos autores: Não há evidências suficientes para fornecer recomendações claras para a prática. Há evidências inconsistentes de que a ultrassonografia universal resulta em aumento significativo no tratamento em comparação com a ultrassonografia realizada apenas em um público alvo ou em comparação com o exame clínico isolado. Nenhuma das estratégias com ultrassonografia tem mostrado melhorar os resultadosclínicos, incluindo displasia de quadril com diagnóstico tardio e cirurgia. Os estudos têm poder insuficiente para detectar diferenças significativas de eventos incomuns. Para crianças com quadris instáveis ou quadris levemente displásicos, a ultrassonografia tardia e a imobilização local reduz o tratamento, sem aumentar significativamente a taxa de displasia diagnosticada tardiamente ou cirurgia.

Orthopedic surgery and mobility goals for children with cerebral palsy GMFCS level IV: what are we setting out to achieve?

BACKGROUND: Multilevel orthopedic surgery is considered to be the gold standard treatment for ambulatory children with cerebral palsy (CP), classified at levels I, II, or III according to the Gross Motor Function Classification System (GMFCS). Hip enlocation and stability are the main goals of orthopedic intervention in the GMFCS level IV subgroup and are well researched; however, there is no evidence to date to support or challenge the effectiveness of orthopedic treatment to preserve functional mobility in this patient group. The aim of this study was to evaluate the results of orthopedic surgery to maintain or restore standing transfers and supported walking in children with CP at GMFCS level IV. METHODS: Twenty-two children with CP GMFCS level IV who underwent orthopedic surgery to improve mobility between the years 2004 and 2008 were included in this study. A retrospective chart review was performed and a satisfaction questionnaire sent to all patients. The primary outcome measure was the attainment and maintenance of mobility goals 2 years post-surgery. The secondary outcome measures were family/patient satisfaction, Functional Mobility Scale (FMS), and complications. RESULTS: The two goals identified by the patients and carers were standing transfers and supported walking. At the 2-year post-surgery assessment, 14 children (63.6 %) did not reach their pre-determined goals. In the questionnaire, 21.4 % of the families reported that surgery was not beneficial. The FMS score remained unchanged in 95.4 % of the patients. Fourteen patients (63.6 %) had at least one complication that prolonged their post-operative rehabilitation (e.g., neuropraxia). CONCLUSION: This study suggests that orthopedic surgery in children with CP at GMFCS level IV is unlikely to maintain or restore mobility. Furthermore, it carries a significant risk of complications. LEVEL OF EVIDENCE: Case series, Level IV.

RADIOGRAPHIC ABNORMALITIES OF THE TALUS IN PATIENTS WITH CLUBFOOT AFTER SURGICAL RELEASE USING THE MCKAY TECHNIQUE.

OBJECTIVE: To analyze morphological abnormalities of the talus in patients with clubfoot after surgical treatment using the McKay technique. METHOD: Lateral standing-position radiographs of the feet of 14 patients with unilateral clubfoot who underwent treatment by means of the doubleincision McKay technique were retrospectively analyzed. All the patients were operated by the same surgeon, with an average of 6.53 years between surgery and the radiograph. We compared the radiographic characteristics of the talus between the operated and the contralateral foot. We assessed the presence of deformity of the talar dome and head (sphericity evaluation); the talar length and height; the percentage and degree of navicular subluxation; abnormalities of the Gissane angle; and the trabecular bone pattern. RESULTS: Abnormalities of the talar head occurred in 92.8% of the patients; of the talar dome in 92.8%; and of the trabecular pattern in 100%. The talar length ratio between the operated and the contralateral foot ranged from 0.61 to 0.88 (mean 0.79; SD = 0.09), while the height ratio ranged from 0.57 to 0.98 (mean 0.82; SD = 0.12). The Gissane angle was greater in all of the operated feet, and all of them also showed navicular subluxation, at a rate ranging from 6.43 to 59.75% (mean 26.34%; SD = 16.66%). CONCLUSION: Talar abnormalities occurred in 100% of the feet treated using the McKay technique. It was shown that establishing radiographic parameters to describe and quantify these deformities was feasible, through simple and easy-to-perform techniques.

Estudo da impressão plantar obtida durante o teste de Jack em crianças / Footprint study in children during the Jack test

OBJETIVO: Avaliar as impressões plantares durante o teste de Jack em crianças quantificando e observando os resultados numa faixa etária crítica para a formação do arco plantar. MÉTODO: Avaliamos 60 crianças brancas (120 pés) sendo 35 meninos e 25 meninas com idades entre 2 e 5 anos, sem queixas ortopédicas. Simulamos o teste de Jack com uma órtese em cunha de 45º apoiada sob o hálux. Obtivemos impressões em apoio monopodálico bilateralmente utilizando um pedígrafo. O exame dividiu-se em duas etapas: com e sem o uso da órtese. A metodologia de Valenti e Volpon foi utilizada para mensurar as impressões plantares e os dados obtidos foram analisados estatisticamente. RESULTADOS: Os valores dos índices de Valenti e Volpon diminuiram quando a órtese foi utilizada. A diferença entre os índices com ou sem órtese diminuiu gradualmente com a progressão etária. CONCLUSÕES: É possível quantificar o teste de Jack pelwas impressões plantares pelo método de Valenti e Volpon. A variação do seu formato apresentou tendência a ser menor a partir dos 4 anos. O teste de Jack perdeu gradativamente a capacidade de modificar a impressão plantar com a idade, diminuindo sua acuidade como parâmetro de bom prognóstico na formação do arco longitudinal medial. Nível de Evidência: Nível IV, estudo descritivo observacional.

OBJECTIVE: To assess the plantar impressions obtained in children during the Jack test, with the aim of quantifying and analyzing their variability in the critical period for plantar foot arch formation. METHOD: A hundred and twenty feet from 60 healthy White children, recruited in an outpatient pediatric clinic, were examined. Our sample included 35 boys and 25 girls, ranging from 2 to 5 years. The Jack test was simulated using a 45o wedge-shaped orthosis applied to the hallux. Bilateral plantar impressions were acquired in the alternate single-foot standing position using a pedigraph. Two plantar impressions were obtained for each foot, with and without the orthosis. The exams were analyzed using the Valenti and Volpon methods. Statistical tests were applied. RESULTS: In all cases, both the Valenti and Volpon indexes decreased as the orthosis was applied. Furthermore, the difference between both indexes with and without the orthosis decreased with age. CONCLUSIONS: It is possible to quantify the Jack test using plantar impressions with the Volpon and Valenti methods. The variability observed in plantar shape tended to decrease after 4 years of age. Finally, the Jack test gradually lost its capability to change plantar impression with age, which reduces its accuracy as a parameter for a good prognosis in longitudinal medial arch formation. Level of Evidence: Level IV, observational descriptive study.

Estudo clínico do quadril não tratado na tetraparesia espástica / Clinical study of untreated hip in spastic tetraparesis

Objetivo: Avaliar quadris de pacientes com tetraparesia espástica considerando a gravidade das deformidades articulares, a idade e a escoliose. Métodos: Realizamos um estudo descritivo transversal de 40 pacientes (um a 17 anos); 21 (52,5 por cento) do sexo feminino e 19 (47,5 por cento) do masculino em pacientes da Associação Cruz Verde; 19 (47,5 por cento) apresentaram prematuridade, 26 (65,0 por cento) anóxia, quatro (10,0 por cento) meningite, 10 (25,0 por cento) hidrocefalia e 15 (37,5 por cento) microcefalia; 38 (95,0 por cento) apresentavam espasticidade, um (2,5 por cento) atetose e um (2,5 por cento) o padrão misto; 28 (70,0 por cento) apresentavam tetraparesia e 12 (30,0 por cento) dupla hemiparesia. Nenhum paciente deambulava, 38 (95,0 por cento) foram classificados como GFMCS V e dois (5,0 por cento) como IV. Consideramos dois grupos, conforme a necessidade ou não do tratamento cirúrgico dos quadris pelo risco de luxação e dor. Utilizamos os testes de Thomas, abdução brusca e Nelaton-Galeazzi. A escoliose foi avaliada pela simetria do tronco e gibosidade. Resultados: Observamos correlação entre a escoliose e a positividade do teste da abdução brusca. Não houve correlação entre a idade e a contratura dos quadris. Não houve diferença entre os tipos topográficos e a contratura do quadril. Conclusões: Não encontramos correlação entre a idade e o grau de contratura articular; pacientes com escoliose apresentaram maior comprometimento da abdução do quadril.

Objective: To evaluate CP patients considering the hip joint and analyzing the relation between severity, age and scoliosis. Methods: A transversal descriptive study was performed in 40 patients (1 to 17 y.o.), 21 (52,5 percent) female and 19 (47,5 percent) male from Cruz Verde Association; 19 (47,5 percent) had history of prematurity; 26 (65,0 percent) with anoxia; meningitis in 4 (10 percent), hydrocephalus in 10(25,0 percent); microcephalus in 15 (37,5 percent). From the total 38 (95,0 percent) presented spasticity, 1 (2,5 percent) athetoid and 1 (2,5 percent) mixed. According to topographic classification 28 (70,0 percent) presented tetraparesis and 12 (30,0 percent) double hemiparesis. All of them are non-ambulators and 38 (95,0 percent) were classified as GFMCS V and 2 (5,0 percent) were level IV. The patients were divided in two groups (with or without indications for hip surgical treatment). The hips were analysed by Thomas, abduction, and Nelaton-Galeazzi tests. The scoliosis was clinically analysed considering trunk symmetry and dorsal hump. Results: We observed positive correlation between the patients’ scoliosis and hip flexion contracture. There was no difference between the patients’ age and and hip flexion contracture. There was no difference between topographic types and hip contractures. Conclusions: We did not find positive correlation between patients’ age and hip contractures; patients with scoliosis present worse hip abduction compromise.

Alterações radiográficas do tálus no pé torto congênito após liberação cirúrgica pela técnica de McKay / Radiographic abnormalities of the talus in patients with clubfoot after surgical release using the McKay technique

OBJETIVO: Analisar as alterações morfológicas do tálus após o tratamento cirúrgico do pé torto congênito pela técnica de McKay. MÉTODO: Foram analisadas, retrospectivamente, radiografias em perfil com carga dos pés de 14 pacientes com pé torto congênito unilateral submetidos ao tratamento pela técnica de McKay por dupla incisão. Todos os pacientes foram operados pelo mesmo cirurgião, com média de 6,53 anos entre a cirurgia e a radiografia. Comparamos as características do tálus dos pés operados com os parâmetros radiográficos dos pés contralaterais. Avaliamos a presença de deformidade do dômus e da cabeça do tálus (avaliação da esfericidade); a altura e o comprimento do tálus; a presença e grau de subluxação do navicular; a alteração do ângulo de Gissane; e o padrão do trabeculado ósseo. RESULTADOS: Alterações da cabeça do tálus ocorreram em 92,8 por cento dos casos; do dômus em 92,8 por cento; e do trabeculado em 100 por cento. A relação entre o comprimento do tálus do pé operado sobre o contralateral variou de 0,61 a 0,88 (média de 0,79; DP = 0,09), e da altura de 0,57 a 0,98 (média de 0,82; DP = 0,12). O ângulo de Gissane aumentou em todos os pés operados, e todos apresentaram subluxação do navicular, com índice variando de 6,43 a 59,75 por cento (média de 26,34 por cento; DP = 16,66 por cento). CONCLUSÃO: Alterações talares ocorreram em 100 por cento dos pés tratados pela técnica de McKay. Estabelecer parâmetros radiográficos para descrever e quantificar essas deformidades mostrou-se viável, através de técnicas simples e de fácil execução.

OBJECTIVE: To analyze morphological abnormalities of the talus in patients with clubfoot after surgical treatment using the McKay technique. METHOD: Lateral standing-position radiographs of the feet of 14 patients with unilateral clubfoot who underwent treatment by means of the double-incision McKay technique were retrospectively analyzed. All the patients were operated by the same surgeon, with an average of 6.53 years between surgery and the radiograph. We compared the radiographic characteristics of the talus between the operated and the contralateral foot. We assessed the presence of deformity of the talar dome and head (sphericity evaluation); the talar length and height; the percentage and degree of navicular subluxation; abnormalities of the Gissane angle; and the trabecular bone pattern. RESULTS: Abnormalities of the talar head occurred in 92.8 percent of the patients; of the talar dome in 92.8 percent; and of the trabecular pattern in 100 percent. The talar length ratio between the operated and the contralateral foot ranged from 0.61 to 0.88 (mean 0.79; SD = 0.09), while the height ratio ranged from 0.57 to 0.98 (mean 0.82; SD = 0.12). The Gissane angle was greater in all of the operated feet, and all of them also showed navicular subluxation, at a rate ranging from 6.43 to 59.75 percent (mean 26.34 percent; SD = 16.66 percent). CONCLUSION: Talar abnormalities occurred in 100 percent of the feet treated using the McKay technique. It was shown that establishing radiographic parameters to describe and quantify these deformities was feasible, through simple and easy-to-perform techniques.