Anatomical study of the safety corridor for bridge plating positioned on the lateral border of the humerus.

PURPOSE: This study shows the danger zone and the safety corridor in the lateral approach with bridge plating by measuring the distance between the lateral side of the plate positioned on the lateral aspect of the humerus and the radial nerve after it pierces the lateral intermuscular septum, in the different forearm positions. METHODS: Forty arms of 20 human cadavers were used, the radial nerve was identified and marked on the lateral surface the radial nerve at the exit of the lateral intermuscular septum and anteriorisation of the nerve in relation to the humeral shaft and the lateral epicondyle was also marked. The distances were measured with a digital caliper. A submuscular extraperiosteal corridor was created, proximally between the biceps brachialis and deltoid muscle and distally between the triceps and brachioradialis muscle, followed by the positioning of the low contact large fragments contoured plate with 14 combined holes (fixed and cortical angle), inserted from distal to proximal. Measurements were performed in four positions (elbow flexion with forearm pronation, elbow flexion with forearm supination, elbow extension with forearm pronation and elbow extension with forearm supination). RESULTS: Significant statistical differences occurred with the different positions, and the elbow flexion with forearm supination was shown to be the position that provides the safest submuscular extraperiosteal corridor in a lateral approach of the humerus. CONCLUSION: The danger zone of radial nerve is an area that extends from 15 cm to 5 cm proximal to the lateral epicondyle and the safest way to create a submuscular and extraperiosteal corridor in the lateral region of the humerus is with the elbow in flexion and the forearm in supination.

EVALUATION OF ARTHROGRYPOTIC FOOT TREATMENT: MINIMUM 10 YEARS FOLLOW-UP.

Objective: To evaluate patients with arthrogryposis submitted to extensive surgical treatment with a minimum of 10 years of follow-up regarding the clinical and radiological aspects and the quality of life, using the 36-Item Short Form (SF-36) and the Disease-Specific Instrument (DSI). Methods: A retrospective study selected 33 patients, totaling 64 operated feet. Results: The mean age of the patients was 17.9 years (12-39 years), and the mean follow-up time was 14.8 years (11-17). Amyoplasia represented 78.7% of syndromic diagnoses. Isolated posteromedial lateral release (PMLR) was performed in 21.8% of the feet, 27.2% of which required additional bone surgery, and about 50 feet (78.1%) were submitted to PMLR, lateral column shortening, and/or talectomy. In total, 46 talectomies were performed (71.8% of the feet), out of which 44 were the first procedure of choice. SF-36 questionnaire was evaluated and showed that 93.9% of the patients did not have restrictive and disabling pain, and the same percentage considered themselves as healthy and had good expectations for the future. Conclusion: Arthrogrypotic feet are difficult to treat, require many recurrent surgical procedures, and relapses are the rule. Stiffness is a common feature of these feet, and residual deformities were frequent. Level of Evidence IV; Case Series, Therapeutic Studies.

Objetivo: Avaliar pacientes com artrogripose submetidos a tratamento cirúrgico convencional com um mínimo de 10 anos de seguimento quanto aos aspectos clínicos, radiológicos e qualidade de vida, utilizando o questionário de 36 itens Short Form 36 (SF-36) e o Instrumento específico de Doenças (IED). Método: No estudo retrospectivo foram avaliados 33 pacientes, totalizando 64 pés operados. Resultados: A média de idade foi de 17,9 anos (12-39 anos), e o tempo médio do seguimento foi de 14,8 anos (11-17). A amioplasia representou 78,7% dos diagnósticos sindrômicos. A liberação posteromedial lateral isolada (LP MI) foi realizada em 21,8% dos pés, 27,2%, com cirurgia óssea adicional, e cerca de 50 pés (78,1%) foram submetidos a LPM (liberação póstero medial), encurtamento da coluna lateral e/ou talectomia. Foram realizadas 46 talectomias (71,8% dos pés), sendo em 44 o procedimento de primeira escolha. O questionário SF-36 evidneciou que 93,9% dos pacientes estavam sem dor restritiva e incapacitante, consideravam-se saudáveis, com boas expectativas para o futuro. Conclusão: Os pés artrogripóticos são de difícil tratamento, requerendo muitos procedimentos cirúrgicos recorrentes. A rigidez é uma característica comum desses pés e as deformidades residuais foram frequentes. Estudos futuros poderão mostrar se haverá diferença no resultado do tratamento desses pés aplicando a abordagem inicial atual, mais conservadora. Nível de Evidência: IV; Estudos Terapêuticos; Série de Casos.

LEARNING CURVE IN PONSETI METHOD - EVOLUTION IN 5 YEAR-INTERVALS.

Objective: Evaluate whether the experience of the surgeon could reduce Ponseti treatment time, and a number of cast changes, and the evolution of the Pirani Score. Methods: 2 reference centers were evaluated. At Institution 1, 254 patients with idiopathic clubfoot (403 feet) were included, and at Institution 2, 32 patients (51 feet). At institution 1 (mentor), 3 intervals of 5 years each were analyzed. At the Institution 2 (trainee), 1 interval of 5 years was analyzed. Results: Patients treated by the mentor had fewer casts compared with the trainee (p < 0.001). At Institution 1, the three mentor intervals showed differences in the number of casts (p < 0.05). A statistically significant difference was observed only in the first mentor interval (2000 to 2005, average of 3.47 casts) compared with the 2 other intervals (2005 to 2010; average of 2.6 casts and 2011 to 2015; average of 2.79 casts; p < 0.0001). Pirani score decreases the most until the third clinic visit. Conclusion: The mentor's greater expertise was associated with fewer casts and shorter time to obtain correction in isolated clubfoot, especially right after the first 5 years of practice. Progression of the Pirani score in both institutions occurs between the first and the third casts. Level of Evidence III; Therapeutic Study, Retrospective Comparative Study.

Objetivo: Avaliar se a experiência no Método Ponseti pode reduzir o tempo de tratamento e o número de gessos. Métodos: Na instituição 1 foram incluídos 254 pacientes com pé torto idiopático (403 pés) e na instituição 2, 32 pacientes (51 pés). Na instituição 1 (mentora) foram analisados 3 intervalos de 5 anos. Na instituição 2 (estagiária), foi analisado 1 intervalo de 5 anos. Resultados: Os pacientes tratados pelo mentor tiveram menos gessos em comparação aos tratados pelo estagiário (p < 0,001). Na Instituição 1, os três intervalos de mentores apresentaram diferenças no número de gessos até a correção dos pés (p < 0,05). Diferença estatisticamente significativa foi observada no primeiro intervalo do mentor (2000 a 2005, média 3,47 gessos) em comparação com os outros 2 intervalos (2005 a 2010; média 2,6 gessos e 2011 a 2015; média 2,79 gessos; p < 0,0001). O escore de Pirani diminui mais até a terceira consulta clínica. Conclusão: A maior expertise do mentor no Método Ponseti esteve associada ao menor número de gessos e ao menor tempo para correção do pé torto, principalmente logo após os primeiros 5 anos. A maior progressão do score de Pirani ocorre entre o primeiro e o terceiro gesso. Nível de Evidência III; Estudo Terapêutico, Estudo Comparativo Retrospectivo.

Effectiveness of the Ponseti method for congenital clubfoot in patients with arthrogryposis: A systematic review and meta-analysis of observational studies.

Purpose: The aim of this systematic review was to address the Ponseti method in arthrogrypotic clubfoot treatment and evaluate the success, complication, and recurrence rates. Method: A systematic review was performed in the PubMed, Scopus, Embase, and Web of Science databases on 9 January 2023, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Success, recurrence, and complication rates were evaluated and analyzed. Risks of bias and the quality of the studies were also evaluated. Results: Five case series, including 53 patients (102 feet), were identified. According to this model, the initial success rate was 91% (95% confidence interval = 0.79-0.96) with I2 = 43%, and the final success was 68% (at 5.8 years of follow-up). Recurrence rate was 30% (95% confidence interval = 0.14-0.52). Conclusion: Ponseti method is indicated in the initial treatment of arthrogrypotic clubfeet, as it is a minimally invasive method with a high correction rate (91%). However, a high recurrence rate (30%) requires early detection and adequate treatment. Level of evidence: Level III. PROSPERO Protocol: CRD42020210373.

SUPERhip Reconstruction Treatment in Patients with Congenital Femoral Deficiency of Paley's Classification Type 1b.

BACKGROUND: Congenital femoral deficiency (CFD) is a challenging and complex condition that causes limb lengthening. We focused on the clinical and radiographic results of SUPERhip procedures in patients with congenital femoral deficiency type 1b, according to Paley's classification, prior to femoral lengthening. METHODS: We reviewed all records and radiographs of patients who underwent this procedure between 2005 and 2020. We included 26 patients, with clinical and radiographic assessments performed during pre- and post-operative evaluations. RESULTS: There were twenty-six patients (15 right vs. 11 left), with a mean age of 7 years (1-18). Most of the patients were female (17 patients; 65.4%). Twenty (76.9%) patients were undergoing their first procedure and six (23.1%) had already undergone a previous surgery. There was a significant improvement in all radiographic parameters, with the mean preoperative and postoperative Neck-Shaft Angle (NSA) being 72.3 ± 7.1° vs. 133.1 ± 12.7°, the Center-Edge Angle (CEA) 16.8 ± 9.8° vs. 33.5 ± 14.1°, and the Acetabular Index (AI) 27.8 ± 6.9° vs. 16.4 ± 6.8°, respectively. The complication rate was 15.4%, predominantly affecting patients under 5 years old. CONCLUSIONS: The SUPERhip procedure is an effective and reproducible technique for clinical and radiographic correction to a significant degree in patients with Paley's type 1b CFD, in preparation for bone lengthening surgery.

Mini-Open Fascia Lata Interposition Graft Results In Superior 2-Year Clinical Outcomes When Compared to Arthroscopic Partial Repair for Irreparable Rotator Cuff Tear: A Single-Blind Randomized Controlled Trial.

PURPOSE: To evaluate and compare the results of surgical treatment for irreparable rotator cuff tear (IRCT) by the mini-open interposition procedure using fascia lata autograft against outcomes of the arthroscopic partial repair technique. METHODS: An interventional, prospective, controlled, randomized, single-blinded study involving 2 study groups was conducted. The graft group (n = 20) underwent the mini-open interposition procedure using fascia lata autograft. The control group (n = 22) underwent arthroscopic partial repair. Patients were evaluated using the University of California Los Angeles (UCLA) Shoulder scale, the American Shoulder and Elbow Surgeons (ASES) score, the Constant-Murley (Constant) score, the visual analogue scale (VAS) pain score, active range of motion, frontal flexion strength, retear rates evaluated by magnetic resonance imaging analysis, occurrence of complications, and the minimal clinically important difference (MCID). RESULTS: The graft group had better UCLA (31.5 vs 28.18, P = .035) (100% exceeded the MCID for the graft group and 95% for the control group), ASES (88.62 vs 77.06, P = .016) (100% exceeded the MCID for both groups), Constant (78.85 vs 61.68, P < .001), and VAS (0.95 vs 2.59, P = .01) scores at the 24-month follow-up. For active forward elevation range, both groups showed no statistically significant differences (168.5 vs 164.54, P = .538). The results for active external and internal rotation were better in the graft group (60.25 vs 40, and 9.1 vs 6.9, P < .001), as was frontal flexion strength (4.24 vs 2.67, P = .005). The graft group also had lower retear rates (15% vs 45.5%, P = .033). No complications were reported. CONCLUSIONS: Outcomes of surgeries for IRCT by the mini-open interposition procedure using fascia lata autograft and by the arthroscopic partial repair technique showed good results in both groups over time and exceeded the MCID. However, most comparative outcomes between groups showed better results for the interposition procedure. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Learning curve in ponseti method - evolution in 5 year-intervals / Curva de aprendizado no método ponseti - evolução em intervalos de 5 anos

ABSTRACT Objective: Evaluate whether the experience of the surgeon could reduce Ponseti treatment time, and a number of cast changes, and the evolution of the Pirani Score. Methods: 2 reference centers were evaluated. At Institution 1, 254 patients with idiopathic clubfoot (403 feet) were included, and at Institution 2, 32 patients (51 feet). At institution 1 (mentor), 3 intervals of 5 years each were analyzed. At the Institution 2 (trainee), 1 interval of 5 years was analyzed. Results: Patients treated by the mentor had fewer casts compared with the trainee (p < 0.001). At Institution 1, the three mentor intervals showed differences in the number of casts (p < 0.05). A statistically significant difference was observed only in the first mentor interval (2000 to 2005, average of 3.47 casts) compared with the 2 other intervals (2005 to 2010; average of 2.6 casts and 2011 to 2015; average of 2.79 casts; p < 0.0001). Pirani score decreases the most until the third clinic visit. Conclusion: The mentor's greater expertise was associated with fewer casts and shorter time to obtain correction in isolated clubfoot, especially right after the first 5 years of practice. Progression of the Pirani score in both institutions occurs between the first and the third casts. Level of Evidence III; Therapeutic Study, Retrospective Comparative Study.

RESUMO Objetivo: Avaliar se a experiência no Método Ponseti pode reduzir o tempo de tratamento e o número de gessos. Métodos: Na instituição 1 foram incluídos 254 pacientes com pé torto idiopático (403 pés) e na instituição 2, 32 pacientes (51 pés). Na instituição 1 (mentora) foram analisados 3 intervalos de 5 anos. Na instituição 2 (estagiária), foi analisado 1 intervalo de 5 anos. Resultados: Os pacientes tratados pelo mentor tiveram menos gessos em comparação aos tratados pelo estagiário (p < 0,001). Na Instituição 1, os três intervalos de mentores apresentaram diferenças no número de gessos até a correção dos pés (p < 0,05). Diferença estatisticamente significativa foi observada no primeiro intervalo do mentor (2000 a 2005, média 3,47 gessos) em comparação com os outros 2 intervalos (2005 a 2010; média 2,6 gessos e 2011 a 2015; média 2,79 gessos; p < 0,0001). O escore de Pirani diminui mais até a terceira consulta clínica. Conclusão: A maior expertise do mentor no Método Ponseti esteve associada ao menor número de gessos e ao menor tempo para correção do pé torto, principalmente logo após os primeiros 5 anos. A maior progressão do score de Pirani ocorre entre o primeiro e o terceiro gesso. Nível de Evidência III; Estudo Terapêutico, Estudo Comparativo Retrospectivo.

Müller-Weiss disease: a functional and quality of life assessment.

PURPOSE: Evaluate the functional health status and quality of life of patients diagnosed with Müller-Weiss disease and, secondarily, determine the influence of factors such as gender, social status, race, body mass index, and surgical and non-surgical treatment in patient outcome. METHODS: This study included 30 affected feet (18 patients) with follow-up from 2002 to 2016. Five patients were excluded from reassessment, resulting in 20 feet (13 patients). Questionnaires for functional and quality of life assessments were administered, and statistical analysis was performed. RESULTS: Patients with obesity had poor functional results and low quality of life rates. Regarding quality of life, mainly in the mental health domain, there was a significant difference (p < 0.001) that was not observed in other domains investigated, except for surgical treatment, which was superior to non-surgical treatment in terms of the physical domain (p = 0.024). Bilateral treatment was also superior to unilateral treatment in Coughlin's classification (71.4% versus 66.7%). CONCLUSIONS: Müller-Weiss disease evolved with poor functional results and low quality of life rates in patients with obesity, with no method of treatment influence on patient outcome, except for the SF-12 physical domain, where surgical treatment showed better results than conservative treatment.

Medical Literature in the Treatment of Clubfoot 1997 - 2021: The Emergence and Spread of the Ponseti Method Over 23 Years.

Background: The Ponseti method of treatment for clubfoot which utilizes serial manipulations and casting in order to achieve correction of the deformity has become increasingly popular due to its robust track record of success without the need for surgical intervention and is considered the gold standard for clubfoot treatment. Exposure of new technology in the scientific literature is associated with the diffusion and adoption of that technology in clinical practice. The aim of this study sought to identify tendencies in the thematic changes in medical literature regarding the treatment of congenital clubfoot over a period of twenty-three years, from 1997 to 2021. Methods: The Medline databases were searched for articles containing the keyword "clubfoot". Articles from 1997 to 2021 were identified and analyzed by institutions which published the articles, and whether treatment was with the Ponseti method or surgical interventions. We also observed in order the geographic diffusion of the Ponseti method. Results: 2067 articles were found in Pubmed referencing clubfoot, and in these publications 577 addressed the Ponseti method and 273 articles discussed surgical treatment. From 1997 - 2000, the only articles discussing the Ponseti Method were from Iowa,in the United States. The increasing number of publications about the Ponseti method and the decrease in publications about surgical treatment for clubfoot occurred after 2003. In 1997, only one country had a publication regarding the Ponseti method; by 2018, 24 countries published articles on the method. Conclusion: These results suggest a trend of dissemination of knowledge to additional countries, reflecting the more widespread usage of the method throughout the world, and global outreach as a result of the work of Ponseti International Association. Level of Evidence: II.

Avascular necrosis of the femoral head in patients with cerebral palsy after hip surgery-incidence and impact on quality of life.

PURPOSE: This study investigated the incidence of AVN in patients with cerebral palsy who underwent a hip reconstruction surgery (soft tissue release, femur and pelvic osteotomies) and its impact on quality of life. METHODS: Retrospective study, with clinical and radiographic analysis of 104 patients (128 hips) GMFCS IV and V with a minimum two year follow-up. Reimers migration percentage, the amount of abduction, acetabular index, and the neck-shaft angle were collected before and after surgery. Modified Tönnis classification was used to analyze the hips before surgery, and the Bucholz and Ogden classification was used to identify hips with AVN. Function and quality of life were investigated with the CPCHILD questionnaire after surgery. RESULTS: The mean age of participants at surgery was 120.1 months (72-184), and it was not related with AVN (p = 0.946). AVN signs were observed in 62 hips (48.5%). The mean pre-op Reimers value was 68.7% (16-100) in normal hips and 83.1% (0-100) in hips with AVN (p = 0.003). All hips considered as Tönnis IV before surgery developed AVN (p = 0.006). The amount of abduction did not differ between hips that developed AVN and those that did not (p = 0.313). Patients who developed AVN had lower scores of quality of life (p = 0.023) and comfort (p = 0.025) according to the CPCHILD questionnaire. CONCLUSION: We observed a relationship between the greater pre-operative severity according to the Reimers index and the modified Tonnis classification and the development of AVN.

PERCUTANEOUS ENDOSCOPIC LUMBAR INTERBODY FUSION: RESULTS OVER 47 MONTHS OF FOLLOW-UP.

Introduction: This study aims to investigate the clinical-functional results of a new surgical technique, Percutaneous Endoscopic Lumbar Interbody Fusion (PELIF), in patients with a clinical diagnosis of low back or sciatic pain and segmental instability who were submitted to surgery using this technique assisted by the attending physician. Materials and methods: Patients completed a consent form and were clinically and radiographically re-assessed by independent evaluators using the visual analog scale (VAS) for pain, the Oswestry Disability Index (ODI), and the SF-36 Quality of Life Score in the pre- and postoperative periods. Their medical records were also reviewed for surgical time, length of hospital stay, need for blood transfusion, return to work, and radiographic fusion evaluation. Results: In the group of 19 patients with 33 levels operated, VAS and ODI decreased from 10.0 and 64% to 2.0 and 28%, respectively. The SF-36 showed significantly higher scores in 5 of its 7 domains at the end of the follow-up as compared to the preoperative period scores. Only 1 case of pseudoarthrosis was diagnosed radiographically. Conclusions: Percutaneous Endoscopic Lumbar Interbody Fusion (PELIF) has been shown to be a safe and efficient technique for the treatment of patients with segmental instability associated with low back or sciatic pain. Level of Evidence VI; Therapeutic Study; Case Series.

Introdução: Este estudo tem como objetivo investigar os resultados clínico-funcionais de uma nova técnica cirúrgica, artrodese lombar endoscópica percutânea (PELIF) em pacientes com diagnóstico clínico de dor lombar ou ciática e instabilidade segmentar, submetidos à referida técnica pelo médico responsável. Materiais e métodos: Os pacientes preencheram um termo de consentimento livre e esclarecido e foram reavaliados clínica e radiograficamente por avaliadores independentes que usaram a Escala Visual Analógica (EVA) para dor, Índice de Incapacidade de Oswestry (ODI) e o Short Form Health Questionnaire SF-36 nos períodos pré e pós-operatório. Foram também pesquisados nos prontuários médicos tempo de cirurgia, tempo de internação hospitalar, necessidade de transfusão de sangue, retorno ao trabalho e avaliação radiográfica da fusão. Resultados: Na amostra final de 19 pacientes com 33 níveis operados, EVA e ODI diminuíram de 10,0% e 64% para 2,0% e 28%, respectivamente. O SF-36 mostrou escores significativamente maiores em 5 de seus 7 domínios no final do acompanhamento, em comparação com o período pré-operatório. Somente 1 caso de pseudoartrose foi diagnosticado por radiografia. Conclusões: A artrodese lombar endoscópica percutânea (PELIF) tem se mostrado uma técnica segura e eficiente para o tratamento dos pacientes com instabilidade segmentar associada a lombalgia ou ciatalgia. Nível de Evidência IV; Estudos Terapêuticos; Série de Casos.

Percutaneous endoscopic lumbar interbody fusion: results over 47 months of follow-up / Artrodese lombar intersomática endoscópica percutânea: resultados depois de 47 meses de acompanhamento

ABSTRACT Introduction This study aims to investigate the clinical-functional results of a new surgical technique, Percutaneous Endoscopic Lumbar Interbody Fusion (PELIF), in patients with a clinical diagnosis of low back or sciatic pain and segmental instability who were submitted to surgery using this technique assisted by the attending physician. Materials and methods Patients completed a consent form and were clinically and radiographically re-assessed by independent evaluators using the visual analog scale (VAS) for pain, the Oswestry Disability Index (ODI), and the SF-36 Quality of Life Score in the pre- and postoperative periods. Their medical records were also reviewed for surgical time, length of hospital stay, need for blood transfusion, return to work, and radiographic fusion evaluation. Results In the group of 19 patients with 33 levels operated, VAS and ODI decreased from 10.0 and 64% to 2.0 and 28%, respectively. The SF-36 showed significantly higher scores in 5 of its 7 domains at the end of the follow-up as compared to the preoperative period scores. Only 1 case of pseudoarthrosis was diagnosed radiographically. Conclusions Percutaneous Endoscopic Lumbar Interbody Fusion (PELIF) has been shown to be a safe and efficient technique for the treatment of patients with segmental instability associated with low back or sciatic pain. Level of Evidence VI; Therapeutic Study; Case Series.

RESUMO Introdução Este estudo tem como objetivo investigar os resultados clínico-funcionais de uma nova técnica cirúrgica, artrodese lombar endoscópica percutânea (PELIF) em pacientes com diagnóstico clínico de dor lombar ou ciática e instabilidade segmentar, submetidos à referida técnica pelo médico responsável. Materiais e métodos Os pacientes preencheram um termo de consentimento livre e esclarecido e foram reavaliados clínica e radiograficamente por avaliadores independentes que usaram a Escala Visual Analógica (EVA) para dor, Índice de Incapacidade de Oswestry (ODI) e o Short Form Health Questionnaire SF-36 nos períodos pré e pós-operatório. Foram também pesquisados nos prontuários médicos tempo de cirurgia, tempo de internação hospitalar, necessidade de transfusão de sangue, retorno ao trabalho e avaliação radiográfica da fusão. Resultados Na amostra final de 19 pacientes com 33 níveis operados, EVA e ODI diminuíram de 10,0% e 64% para 2,0% e 28%, respectivamente. O SF-36 mostrou escores significativamente maiores em 5 de seus 7 domínios no final do acompanhamento, em comparação com o período pré-operatório. Somente 1 caso de pseudoartrose foi diagnosticado por radiografia. Conclusões A artrodese lombar endoscópica percutânea (PELIF) tem se mostrado uma técnica segura e eficiente para o tratamento dos pacientes com instabilidade segmentar associada a lombalgia ou ciatalgia. Nível de Evidência IV; Estudos Terapêuticos; Série de Casos.

Risk Factors Associated With Foot and Ankle Insufficiency Fractures in Postmenopausal Sedentary Women.

BACKGROUND: Insufficiency fractures occur in bones with low elastic resistance. In contrast to stress fractures, which affect normal bones and have been extensively studied, insufficiency fractures of the foot and ankle have been the subject of little research. The objective of this study was to identify risk factors associated with the development of foot and ankle insufficiency fractures. METHODS: The study included 55 postmenopausal sedentary women with foot and ankle insufficiency fractures and 51 women in the control group. The data collected were the fracture site, body mass index, use of corticosteroids, T scores of the femur and lumbar spine measured by bone densitometry, and serum 25-OH vitamin D level. The calcaneal pitch (CP), talar-first metatarsal, and metatarsus adductus (MA) angles were measured on radiographs. RESULTS: In 49 patients (89%), fractures occurred in the metatarsals. All metatarsals were affected, and the most common fracture site was the base of the fifth metatarsal, with 21 cases (33%). Twenty patients (36%) in the study group reported chronic use of corticosteroids and had lower bone mineral density levels than controls (P < .05). The factors associated with fracture development (P < .05) were the CP and MA angles and low lumbar bone mineral density. CONCLUSION: Insufficiency fractures in this population were associated with low bone mineral density and unfavorable biomechanical characteristics such as pes cavus and metatarsus adductus. LEVEL OF EVIDENCE: Level IIIB, case-control study.

PONSETI METHOD IN BRAZIL: FIRST TEN YEARS OF A CLUBFOOT WEBSITE - USERS PROFILE.

OBJECTIVE: To analyze the profiles of the individuals who access the website regarding congenital clubfoot (CC) information and the first ten years of Ponseti method implementation in Brazil. METHODS: This is a retrospective documentary study, with quantitative database analysis, from 2002 to 2012. Parents or caregivers completed a semi-structured questionnaire regarding the main difficulties encountered, the search for different professionals in the area, and what were the main questions the reader might have when searching on a technical website. RESULTS: In total, 94% of participants had a family member or acquaintance with CC, most participants were women (74%), higher education level (40%), married (75%), income above one minimum wage (80%), working in administrative positions (21%,) and living in the urban area (99%). Of the participants, 44% sought three or more physicians at the beginning of treatment, and an average of 77% of the participants used health insurance or a private physician. CONCLUSION: The participants' profile regarding CC is composed of women, married, living in urban areas, predominantly from Southeastern Brazil, higher education level, with income above 1.5 minimum wages, and who were treating their children with a private physician. Level of Evidence II, Retrospective study.

OBJETIVO: Analisar o perfil de indivíduos que acessam o site de informações sobre o pé torto congênito (PTC) e o tratamento do Método Ponseti nos primeiros dez anos da implantação do método no Brasil. MÉTODOS: Trata-se de um estudo retrospectivo com análise de bases de dados, de caráter quantitativo, de 2002 a 2012. Aplicou-se um questionário semiestruturado que abordou as dificuldades encontradas, busca por diferentes profissionais e quais eram as principais dúvidas. RESULTADOS: dos respondentes, 94% tinham algum familiar com PTC, os respondentes foram 74% do sexo feminino, 40% com ensino superior, 75% casados(as), 80% com renda acima de um salário mínimo, 21% de cargos administrativos e 99% residentes em área urbana. Dos respondentes, 44% procuraram três ou mais médicos no início do tratamento, e, em média, 77% fizeram o tratamento usando convênio médico ou usando médico particular. CONCLUSÃO: O perfil de indivíduos que acessam o site de informações sobre PTC e o tratamento do Método Ponseti é composto de respondentes do sexo feminino, casadas, residentes em área urbana, predominantemente do sudeste do Brasil, com ensino superior, com renda acima de 1,5 salários mínimos, e que estavam tratando seus filhos pela rede de saúde particular. Nível de Evidencia II, Estudo retrospectivo.

QUALITY OF LIFE AND CHALLENGES OF FAMILY MEMBERS OF CHILDREN WITH MENINGOMYELOCELE.

OBJECTIVE: To identify the main challenges of the family of a child with meningomyelocele (MMC) and correlate the Zarit Burden Interview (ZBI) scale with the World Health Organization Quality of Life-BREF (WHOQOL - BREF). METHODS: Questionnaires were sent through an online platform to groups of parents and caregivers of children with MMC. Four WHOQOL-BREF domains were evaluated: physical, psychological, social and environmental. RESULTS: All correlations among the domains of the WHOQOL-BREF questionnaire with the Zarit Burden Interview (ZBI) scale were negative and significant with a higher magnitude value for ZBI × psychological domain with - 57.4% correlation (p < 0.001). CONCLUSION: The results of this study suggest the quality of life of mothers and caregivers of children with meningomyelocele is affected regarding functional capacity, emotional aspect, and mental health. Despite this, the participants present a positive view of their lives. The most common difficulties faced by caregivers were: performing bladder catheterization, providing general care, financial burden, and accessibility. Level of Evidence V, Expert opinion.

OBJETIVO: identificar os principais desafios da família de uma criança com Mielomeningocele (MMC) e correlacionar a escala de Zarit Burden Interview (ZBI) com o WHOQOL-BREF. MÉTODOS: Foram enviados questionários via plataforma on-line para grupos de pais e cuidadores de crianças com MMC. Quatro dimensões foram avaliadas: física; psicológica; relações sociais; e meio ambiente do WHOQOL-BREF. RESULTADOS: Todas as correlações entre os domínios do questionário WHOQOL-BREF com a escala de Zarit Burden Interview (ZBI) foram negativas e significativas com maior magnitude de valor para ZBI × domínio psicológico com − 57,4% de correlação (p < 0,001). CONCLUSÃO: Os resultados desse estudo sugerem que a qualidade de vida das mães e cuidadores de crianças com MMC é afetada em relação a capacidade funcional, aspecto emocional e saúde mental. Apesar disso, apresentam uma visão positiva de sua vida. As dificuldades mais encontradas pelos cuidadores foram: realizar o cateterismo vesical; prestar cuidados gerais; financeira; sobrecarga de trabalho; e acessibilidade. Nível de Evidência V, Opinião do especialista.

Qualidade de vida e desafios de familiares de crianças com mielomeningocele / Quality of life and challenges of family members of children with meningomyelocele

RESUMO Objetivo: identificar os principais desafios da família de uma criança com Mielomeningocele (MMC) e correlacionar a escala de Zarit Burden Interview (ZBI) com o WHOQOL-BREF. Métodos: Foram enviados questionários via plataforma on-line para grupos de pais e cuidadores de crianças com MMC. Quatro dimensões foram avaliadas: física; psicológica; relações sociais; e meio ambiente do WHOQOL-BREF. Resultados: Todas as correlações entre os domínios do questionário WHOQOL-BREF com a escala de Zarit Burden Interview (ZBI) foram negativas e significativas com maior magnitude de valor para ZBI × domínio psicológico com − 57,4% de correlação (p < 0,001). Conclusão: Os resultados desse estudo sugerem que a qualidade de vida das mães e cuidadores de crianças com MMC é afetada em relação a capacidade funcional, aspecto emocional e saúde mental. Apesar disso, apresentam uma visão positiva de sua vida. As dificuldades mais encontradas pelos cuidadores foram: realizar o cateterismo vesical; prestar cuidados gerais; financeira; sobrecarga de trabalho; e acessibilidade. Nível de Evidência V, Opinião do especialista.

ABSTRACT Objective: To identify the main challenges of the family of a child with meningomyelocele (MMC) and correlate the Zarit Burden Interview (ZBI) scale with the World Health Organization Quality of Life-BREF (WHOQOL - BREF). Methods: Questionnaires were sent through an online platform to groups of parents and caregivers of children with MMC. Four WHOQOL-BREF domains were evaluated: physical, psychological, social and environmental. Results: All correlations among the domains of the WHOQOL-BREF questionnaire with the Zarit Burden Interview (ZBI) scale were negative and significant with a higher magnitude value for ZBI × psychological domain with − 57.4% correlation (p < 0.001). Conclusion: The results of this study suggest the quality of life of mothers and caregivers of children with meningomyelocele is affected regarding functional capacity, emotional aspect, and mental health. Despite this, the participants present a positive view of their lives. The most common difficulties faced by caregivers were: performing bladder catheterization, providing general care, financial burden, and accessibility. Level of Evidence V, Expert opinion.

Ponseti method in brazil: first ten years of a clubfoot website - users profile / Método ponseti no brasil: 10 anos de um site sobre pé torto - perfil de usuários

ABSTRACT Objective: To analyze the profiles of the individuals who access the website regarding congenital clubfoot (CC) information and the first ten years of Ponseti method implementation in Brazil. Methods: This is a retrospective documentary study, with quantitative database analysis, from 2002 to 2012. Parents or caregivers completed a semi-structured questionnaire regarding the main difficulties encountered, the search for different professionals in the area, and what were the main questions the reader might have when searching on a technical website. Results: In total, 94% of participants had a family member or acquaintance with CC, most participants were women (74%), higher education level (40%), married (75%), income above one minimum wage (80%), working in administrative positions (21%,) and living in the urban area (99%). Of the participants, 44% sought three or more physicians at the beginning of treatment, and an average of 77% of the participants used health insurance or a private physician. Conclusion: The participants' profile regarding CC is composed of women, married, living in urban areas, predominantly from Southeastern Brazil, higher education level, with income above 1.5 minimum wages, and who were treating their children with a private physician. Level of Evidence II, Retrospective study.

RESUMO Objetivo: Analisar o perfil de indivíduos que acessam o site de informações sobre o pé torto congênito (PTC) e o tratamento do Método Ponseti nos primeiros dez anos da implantação do método no Brasil. Métodos: Trata-se de um estudo retrospectivo com análise de bases de dados, de caráter quantitativo, de 2002 a 2012. Aplicou-se um questionário semiestruturado que abordou as dificuldades encontradas, busca por diferentes profissionais e quais eram as principais dúvidas. Resultados: dos respondentes, 94% tinham algum familiar com PTC, os respondentes foram 74% do sexo feminino, 40% com ensino superior, 75% casados(as), 80% com renda acima de um salário mínimo, 21% de cargos administrativos e 99% residentes em área urbana. Dos respondentes, 44% procuraram três ou mais médicos no início do tratamento, e, em média, 77% fizeram o tratamento usando convênio médico ou usando médico particular. Conclusão: O perfil de indivíduos que acessam o site de informações sobre PTC e o tratamento do Método Ponseti é composto de respondentes do sexo feminino, casadas, residentes em área urbana, predominantemente do sudeste do Brasil, com ensino superior, com renda acima de 1,5 salários mínimos, e que estavam tratando seus filhos pela rede de saúde particular. Nível de Evidencia II, Estudo retrospectivo.

Ponseti Method After Walking Age - A Multi-Centric Study of 429 Feet: Results, Possible Treatment Modifications and Outcomes According to Age Groups.

Objective: Ponseti method is suitable to treat neglected clubfoot after the walking age. However, limited evidence exists on its effectiveness, outcomes and rate of relapse. Methods: 429 clubfeet in 303 patients with no previous treatment and older than one-year were treated with the Ponseti method in 15 centers from seven countries. The median age at treatment onset was three years, and the median follow-up of 1.3 years. Standard Ponseti Method was applied. Bilateral abduction brace was recommended after casting. Patients were classified according to group ages (<2 years, 2-4 years, >4-8years, >8 years). Feet were evaluated by Pirani score and a clinical outcome classification. Relapses were described in a subset of 103 clubfeet with minimal follow-up of two years. Results: Ponseti method was able to correct the deformity in 87% (373 of 429) of neglected clubfeet, after a mean of 6.8 casts. Residual equinus was treated with percutaneous sectioning of the Achilles tendon in 356 (83%) of 429 clubfeet. A bilateral foot abduction brace was prescribed and used in 70% of children. Relapses occurred in 31% (32 of 103) of clubfeet and were associated with age less than 4 years at treatment onset, and bracing noncompliance. Conclusion: The Ponseti method is effective to correct neglected clubfeet. Relapses occurred in one-third of clubfeet, mainly in children younger than four years and in noncompliance with the brace. Our study reinforces the recommendation for the Ponseti method with no major modification to treat neglected clubfoot in patients after walking age.Level of Evidence: IV.

Comparison of the recanalization rate and postthrombotic syndrome in patients with deep venous thrombosis treated with rivaroxaban or warfarin.

BACKGROUND: In this article, we report the outcomes of patients with deep venous thrombosis in the lower limbs treated with the oral anticoagulant rivaroxaban or warfarin, focusing on the recanalization rate (measured with duplex ultrasound) and the incidence of postthrombotic syndrome. METHODS: This was a prospective, consecutive, randomized, blind cohort study of patients admitted with deep venous thrombosis to the Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual, São Paulo, Brazil, between March 2016 and July 2018. The patients were randomized into 2 groups and treated with oral anticoagulation for 6 months: either rivaroxaban (group 1) or warfarin (group 2). The study was registered at clinicaltrials.gov under NCT 02704598. RESULTS: Eighty-eight patients with deep venous thrombosis were admitted to the Vascular Surgery Department and randomized into the 2 groups. The follow-up time was 360 days. Analyses were performed at 180 and 360 days. Four patients were excluded from the study during follow-up because of a diagnosis of ovarian cancer (1 patient), head and neck cancer (1 patient), lung cancer (1 patient), and stomach cancer (1 patient). Therefore, 84 patients were evaluated: 46 patients in group 1 and 38 in group 2. The incidence of postthrombotic syndrome was 17.9% (15 cases) in the total cohort, but was significantly higher in group 2 (11 cases, 28.9%) than in group 1 (4 cases, 8.7%; P < .001; odds ratio, 4.278). The rate of total venous recanalization at 360 days was 40.5% (34 patients) in the total cohort, but was significantly higher in group 1 (35 patients, 76.1%) than in group 2 (5 patients, 13.2%; P < .001). The incidence of partial venous recanalization was 46.4% and was significantly higher in group 2 (28 patients, 73.7%) than in group 1 (11 patients, 23.9%; P = .016). Five patients in the total cohort (6%) showed no venous recanalization, all of them in group 2 (P = .016). CONCLUSION: In this study, patients who received oral rivaroxaban displayed a lower incidence of postthrombotic syndrome and a better total vein recanalization rate after 6 and 12 months than patients who received warfarin.

The Ponseti method in children with clubfoot after walking age - Systematic review and metanalysis of observational studies.

BACKGROUND: The prevalence of untreated congenital clubfoot among children older than walking age is higher in developing countries due to limited resources for early care after birth. The Ponseti method represents an intervention option for older, untreated children. METHODS: A metanalysis was conducted of observational studies selected through a systematic review of articles included in electronic databases (Medline, Scopus, Embase, Lilacs, and the Cochrane Library) until June 2017. A pooling analysis of proportions with 95% confidence intervals (CIs) and a publication bias assessment were performed as routine. Estimates of success, recurrence, and complication rates were weighted and pooled using the random effects model. RESULTS: Twelve studies, including 654 feet diagnosed with congenital clubfoot in children older than walking age (older than 1 year old), were included for analysis. The rate of satisfactory outcomes found via a cluster metanalysis of proportions using the random effects model was 89% (95% CI = 0.82-0.94, p < 0.01), relative to the total analysed. The recurrence rate was 18% (95% CI = 0.14-0.24, p = 0.015), and the rate of casting complications was 7% (95% CI = 0.03-0.15, p = 0.19). CONCLUSION: Application of the Ponseti method in children with untreated idiopathic clubfoot older than walking age leads to satisfactory outcomes, has a low cost, and avoids surgical procedures likely to cause complications. The results obtained exhibited considerable heterogeneity.