Surgical technique: Medial column arthrodesis in rigid spastic planovalgus feet.

BACKGROUND: Treatment of spastic planovalgus feet is challenging, especially in patients with severe and rigid deformities. The available techniques do provide some correction but not at the site of the deformity and sometimes the correction is lost over time. We describe a new surgical approach at the site of the deformity. TECHNIQUE: Indications for the surgery included adolescents or young adults with severe and rigid planovalgus deformities of the feet resulting from cerebral palsy. Through a medial approach, arthrodesis of the talonavicular, navicular-medial cuneiform, and medial cuneiform first metatarsal joints was internally fixed using a single-molded plate over the plantar surface of the foot, recreating the longitudinal arch. METHODS: We retrospectively reviewed 21 patients (35 feet) with spastic cerebral palsy in whom the new technique was indicated for severe and rigid deformity, gait dysfunction, and pain (mean age, 190 months; range, 96-345 months). The mean age of the patients was 16 years (range, 8-29 years). We analyzed the patients clinically and radiographically. The minimum followup was 2.5 years (mean, 58 months; range, 2.5-7.5 years). RESULTS: At last followup, 34 of the 35 feet (97%) had radiographic improvement of the deformity with no difficulties wearing shoes; one patient had persistent pain despite bone union. Union was achieved initially in eight patients (17 feet) and in another eight (10 feet) after revision surgery, of 27 of the 35 feet. The radiographic calcaneal inclination angle improved an average of 13°. The lateral talocalcaneal angle decreased from a mean of 43° to 26° after surgery. Four patients (five feet) had revision surgery for pseudoarthrosis, and another four patients (five feet) had revision surgery for other problems. CONCLUSIONS: Based on our preliminary observations, we believe stabilization of the medial column is a reasonable option for treating selected patients with severe and rigid planovalgus feet by providing a stable and pain-free foot, recreating the anatomy, and allowing the use of braces or regular shoes. Further studies with longer followup periods will be required to confirm these initial results and to verify if these findings persist over time. LEVEL OF EVIDENCE: Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

O tratamento do pé artrogripótico / Treatment of the arthrogrypotic foot

A artrogripose é um termo utilizado para definir a presença, ao nascimento, de múltiplas contraturas articulares. A amioplasia é a principal e mais freqüente doença que cursa com contraturas congênitas e deformidade em eqüinovaro dos pés. A maioria dessas crianças tem bom potencial para a deambulação, havendo a necessidade da correção da deformidade dos pés para a posição plantígrada. O tratamento desses pés continua sendo um desafio devido à rigidez característica da doença e ao alto risco de recidiva. Os autores apresentam as opções de tratamento com base em uma revisão ampla da literatura, discutindo as técnicas cirúrgicas convencionais, como as liberações de partes moles e a talectomia, e a correção com o aparelho de Ilizarov. Ressaltam os estudos com resultados do tratamento primário do pé artrogripótico, na tentativa de fundamentar e auxiliar o ortopedista nesta difícil escolha.

Arthrogryposis is the name used to define the presence of multiple joint contractures at birth. Amyoplasia is the main and most frequent among the diseases that take place with congenital contractures and equinovarus deformity of the foot. Most of these children have a good potential for walking, and a correction is required to correct their feet to the plantigrade position. Treatment of these feet presents a challenge due to the characteristic rigidity of the disease and to the high risk of recurrence. The authors present the treatment options based on a broad review of the literature, and discuss the conventional surgical techniques, such as the release of soft tissues and talectomy, and the correction of Ilizarov's device. They point to the studies that show the results of primary treatment of the arthrogrypotic foot in an attempt of providing a basis and giving a support to the orthopedist in this difficult choice.

Displasia fibrocartilaginosa focal: uma forma rara de genuvaro de correção espontânea / Focal fibrocartilaginous dysplasia: a rare form of spontaneously corrected varus knee

A displasia fibrocartilaginosa focal (DFF) é caracterizada por um defeito metafisário com a presença local de tecido fibrocartilaginoso e representa uma das causas de genuvaro unilateral em crianças de baixa idade. Foi inicialmente descrita na face medial da tíbia. Relatos mais recentes referem-na também no fêmur, úmero e ulna. Sua baixa freqüência, constatada pelos poucos relatos, pode ocultar o viés da falta de diagnóstico devido à tendência de correção espontânea, tomando-se importante o seu reconhecimento. Os autores relatam seis novos casos de DFF, todos em meninas, com idade entre 14 e 22 meses -média de 18 meses- envolvendo quatro tíbias e dois fêmures. O objetivo do trabalho foi enfatizar a necessidade do diagnóstico precoce. Após o tempo médio de seguimento de 40 meses (14 a 83 meses) observou-se que a correção natural ocorreu em todos os casos até em torno dos quatro anos de idade. Os autores alertam para o risco de negligência no diagnóstico da afecção que deve ser lembrada no diferencial do genuvaro na criança de baixa idade e, devido à evolução favorável, aconselham a observação clínica, que pode evitar procedimentos invasivos e desnecessários