Tratamento cirúrgico do pé torto equinovaro congênito idiopático: avaliaçäo pó-operatória de 164 pés / Surgical treatment of congenital clubfoot: postoperative evaluation of 164 feet

A via de acesso de Cincinnati foi utilizada em 111 pacientes (164 pés) portadores de pé torto eqüinovaro congênito (PTC) no período de 1985 a 1994. Os autores descrevem a técnica cirúrgica empregada e as facilidades que envolvem a abordagem das regiöes medial, posterior e lateral através dessa via de acesso. Os resultados säo analisados por um sistema de avaliaçäo funcional que permite, por meio de exame clínico e radiográfico, classificá-los em excelentes, bons, regulares e ruins. Os autores, entretanto, sugerem que os resultados excelentes e bons sejam denominados satisfatórios e os regulares e ruins, insatisfatórios. A análise comparativa entre duas faixas etárias é submetida ao estudo estatístico. Dessa forma, foi possível concluir que a idade influenciou significantemente os resultados obtidos.

Arthroplasty of the knee--indications and contraindications.

Total knee arthroplasty has been showed to be a satisfactory procedure mainly in relation to designs evolution of condylar or surface prostheses. In this matter, the concepts of prostheses of Gunston Polycentric (2), Freeman-Swanson (1) and the Total Condylar (3) were particularly important. The present status of development of condylar or surface arthroplasties allows to establish that in the majority of cases, arthrodesis of the knee is a salvage procedure. The alternative procedures indicated must always be considered. The conservative treatments as anti-inflammatory drugs and physiotherapy as well as arthroscopy, arthrotomy, synovectomy and osteotomies can be performed. These procedures are indicated depending on age, joint condition and type of disease. The knee arthroplasty requires skill and training of the surgeon, particularly if we consider the deformities and instabilities to be corrected and joint function to be aimed. On the other hand, the major problem may be the selection of the patient who will be operated on for a given type of total knee arthroplasty.

Knee arthroplasty rating.

A number of rating systems used to evaluate the results of total knee arthroplasty exist. Many of these systems are based on different concepts, and might be expected to give divergent results. To see if this was so, the authors examined a consecutive series of 235 posterior stabilized knee arthroplasties recording the results according to five rating systems: HSS (The Hospital for Special Surgery), Brigham, Freeman, BOA (British Orthopaedic Association), and the VENN diagram. In spite of their apparent differences, all point systems and the BOA gave almost identical results, while the VENN diagram proved to be the most stringent. The authors suggest that any of the current point systems may be used to "score" arthroplasties, but the results should also be rated with the VENN diagram in order to see the quality of the arthroplasty and a comparison between the different series.

Arterial abnormalities in talipes equinovarus as assessed by angiography and the Doppler technique.

Preoperative angiography in 30 uncorrected clubfeet demonstrated abnormal vascular patterns in all but two limbs with hypoplasia or premature termination of the anterior tibial and medial plantar arteries in the remainder. Postoperative Doppler studies in nine of the limbs with abnormal vessels indicated that these arteries were present. We suggest that the continuous-wave Doppler technique is less useful for identifying major arteries than either dissection or angiography. Furthermore, arterial dysgenesis may play a role in the etiology of clubfoot. Since the posterior tibial artery usually provides the sole arterial supply to the foot, this vessel must be preserved at surgery and during subsequent ankle dorsiflexion.

Total knee arthroplasty without patellar resurfacing.

Twenty-seven knees treated between 1974 and 1980 had a total condylar type knee arthroplasty without patellar resurfacing; the average follow-up period was 5.2 years. Compared with a previously reported group of 100 consecutive total condylar arthroplasties, the overall results in this series were very similar. However, there was a significant difference in stair-climbing ability, and one-third of the patients could not use the operated knee for this activity. In most knees the patella could be resurfaced. A working hypothesis assumes that the patellar button can be omitted in patients with relatively normal patellar cartilage, or relatively young, active, or obese patients who are considered a high risk for patellar bone fractures.

Total knee arthroplasty.

The standard prosthesis for most arthritic conditions is a tricompartmental type. Patellar resurfacing should be done in most cases. The question of cruciate preservation or substitution is unresolved, and both types give equivalent clinical results. No advantage has been shown for left or right components. Correction of deformity occurs by soft-tissue release and ligament balancing, rather than by bone resection. Most primary replacements can be performed in this manner, but alignment is critical to the function and survival of a functioning arthroplasty. Most failures can be attributed to incorrect ligament balance or incorrect alignment. Cement fixation of the components has proved effective, and there is no immediate need for alternative methods such as bone ingrowth; new methods will have to prove themselves against the standard already established for cemented prostheses. Patellar complications such as fatigue fracture of the patellar bone now constitute the majority of problems following total knee arthroplasty.