Quality of life and clinical outcomes in severely involved cerebral palsy patients and spastic hips undergoing Castle surgery: a cross-sectional study.

PURPOSE: As progressive hip dislocation causes pain in children with spastic cerebral palsy (CP) and spasticity needs surgical correction, we aimed to describe clinical and radiographic outcomes in CP patients with painful hip deformity treated with the Castle salvage procedure. METHODS: We included all patients operated in the same hospital between 1989 and 2017 with painful spastic hips and femoral head deformity making joint reconstruction unfeasible. We collected clinical and functional data from medical records and evaluated radiographies to classify cases for femoral head shape and migration, type of deformity, spinal deformity, and heterotopic ossification. We investigated quality of life one year after surgery. RESULTS: We analyzed 41 patients (70 hips) with complete medical records. All had severe function compromise GMFCS V (Gross Motor Function Classification System) and heterotopic ossifications, all but one had scoliosis, and most had undergone other surgeries before Castle procedure. Patients were followed up for 77.1 months (mean) after surgery. The mean initial migration index was 73%. Seven patients had complications, being three patients minor (two femur and one tibial fracture) and four majors (patients requiring surgical revision). Quality of life was considered improved by most of the carers (35 children; 85.3%) as level 4/5 according to CPCHILD instrument. No child was able to stand or walk, but moving in and out of bed, of vehicles, and to a chair, remaining seated, or visiting public places was "very easy." CONCLUSION: We considered most patients (37 patients-90%, 66 hips-94%) as having satisfactory outcomes because they had no or minor complications, absence of pain, free mobility of the lower limbs and were able to sit in a wheelchair.

Spastic Hips in Cerebral Palsy - Retrospective Study of Salvage with the McHale Procedure.

Objective To perform a retrospective and cross-sectional assessment to determine the pain and positional improvement of all patients with spastic cerebral palsy (CP) and severe hip deformity who underwent a McHale procedure in our center. A second objective was to analyze the potential complications from the procedure. Methods All consecutive patients treated between 1995 and 2017 were analyzed. Clinically, the patients should present pain on hip mobilization, difficulty in positioning for sitting and hygiene care, and medical records with complete data; functionally was assessed through the Gross Motor Function Classification System (GMFCS). In the preoperative radiographs, we analyzed the migration percentage (MP), the type of deformity according to the Melbourne Cerebral Palsy Hip Classification Scale (MCPHCS), and the type of deformity of the femoral head. After the surgery, we assessed the proximal migration of the proximal femoral fragment, implant changes and/or failure, and potential heterotopic ossification. The outcomes were reported as successful (D1) in patients presenting remission of pain, painless mobility, and improved positioning, or unsuccessful (D2) in those presenting procedural failure that required a new surgery. Results In total, 47 patients (53 hips) were treated. Functionally, 43 patients were classified as GMFCS V (91%), 3 as GMFCS IV patients (6%), and 1 as GMFCS III (2%). The mean age was 13 years and 2 months. The follow-up ranged from 1 year to 15 years and 4 months, with an average of 4 years and 8 months. A total of 36 patients (41 hips) presented successful (D1) outcomes after the McHale procedure, corresponding to 77% of our cases, whereas 11 (23%) cases had unsuccessful (D2) outcomes. Conclusion The McHale procedure is a treatment option for GMFCS IV and V, but we must be aware of the potential complications.

Spastic Hips in Cerebral Palsy - Retrospective Study of Salvage with the McHale Procedure / Quadris espásticos da paralisia cerebral - Estudo retrospectivo do salvamento com a cirurgia de McHale

Abstract Objective To perform a retrospective and cross-sectional assessment to determine the pain and positional improvement of all patients with spastic cerebral palsy (CP) and severe hip deformity who underwent a McHale procedure in our center. A second objective was to analyze the potential complications from the procedure. Methods All consecutive patients treated between 1995 and 2017 were analyzed. Clinically, the patients should present pain on hip mobilization, difficulty in positioning for sitting and hygiene care, and medical records with complete data; functionally was assessed through the Gross Motor Function Classification System (GMFCS). In the preoperative radiographs, we analyzed the migration percentage (MP), the type of deformity according to the Melbourne Cerebral Palsy Hip Classification Scale (MCPHCS), and the type of deformity of the femoral head. After the surgery, we assessed the proximal migration of the proximal femoral fragment, implant changes and/or failure, and potential heterotopic ossification. The outcomes were reported as successful (D1) in patients presenting remission of pain, painless mobility, and improved positioning, or unsuccessful (D2) in those presenting procedural failure that required a new surgery. Results In total, 47 patients (53 hips) were treated. Functionally, 43 patients were classified as GMFCS V (91%), 3 as GMFCS IV patients (6%), and 1 as GMFCS III (2%). The mean age was 13 years and 2 months. The follow-up ranged from 1 year to 15 years and 4 months, with an average of 4 years and 8 months. A total of 36 patients (41 hips) presented successful (D1) outcomes after the McHale procedure, corresponding to 77% of our cases, whereas 11 (23%) cases had unsuccessful (D2) outcomes. Conclusion The McHale procedure is a treatment option for GMFCS IV and V, but we must be aware of the potential complications.

Resumo Objetivo Fazer uma avaliação retrospectiva e transversal quanto à melhora da dor e do posicionamento de todos os pacientes portadores de paralisia cerebral (PC) espástica com deformidade grave no quadril submetidos ao procedimento de McHale em nosso centro. Secundariamente, objetivou-se analisar as possíveis complicações do procedimento. Métodos Foram analisados todos os pacientes consecutivos tratados no período entre 1995 e 2017. Clinicamente, os pacientes deveriam apresentar dor à mobilização do quadril, dificuldade de posicionamento para se sentar e para os cuidados de higiene, e prontuário médico com dados completos; quanto ao grau de função motora, utilizou-se o Sistema de Classificação da Função Motora Grossa (Gross Motor Function Classification System, GMFCS, em inglês). A avaliação radiográfica no período pré-operatório analisou a porcentagem de migração (PM), o tipo de deformidade de acordo com a Escala de Classificação de Quadril na Paralisia Cerebral de Melbourne (Melbourne Cerebral Palsy Hip Classification Scale, MCPHS), e a deformidade da cabeça femoral. No período pós-operatório, analisaram-se a presença de migração proximal do fragmento do fêmur proximal, as alterações e/ou a falha do implante utilizado, e a possível ossificação heterotópica. Consideraram-se como desfechos: D1- satisfatório: remissão da dor, mobilidade indolor, melhora do posicionamento; e D2- insatisfatório: falha no procedimento, que necessitou de reabordagem cirúrgica. Resultados No total, 47 pacientes (53 quadris) foram tratados. Funcionalmente, quanto à classificação no GMFCS, 43 pacientes eram GMFCS V (91%), 3 pacientes eram GMFCS IV (6%), e 1 paciente era GMFCS III (2%). A média da idade foi de 13 anos e 2 meses. O tempo de seguimento variou de 1 ano a 15 anos e 4 meses, com média de 4 anos e 8 meses. Quanto ao desfecho da cirurgia de McHale, ele foi satifatório (D1) em 36 pacientes (41 quadris), perfazendo 77% dos nossos casos, e insatisfatório (D2) em 11 (23%) casos. Conclusão A cirurgia de McHale é uma opção no tratamento para os níveis IV e V, mas devemos estar alertas para as possíveis complicações.

Long-term results of fibular-Achilles tenodesis (Westin's tenodesis) for paralytic pes calcaneus: is hypercorrection avoidable? A longitudinal retrospective study.

PURPOSE: The purpose of this study was to review all cases of patients submitted to Westin's tenodesis, who had calcaneus feet secondary to myelomeningocele sequel, in order to evaluate the anatomical change provided by surgery and also to verify, in a long-term follow-up, the inversion of the deformity depending on the patient's age. METHODS: In this longitudinal retrospective study, all medical records of patients with myelomeningocele sequelae submitted to Westin's tenodesis from 1993 to 2013 in a public university hospital were reviewed. Patients were contacted for new clinical and radiographic evaluations after a minimum of 36 months after surgery. The calcaneotibial angle was measured and the shortening of the fibula was calculated as the "intermalleolar height". RESULTS: The study was based on 16 children (26 feet), aged 84.27 months on average at the time of tenodesis. The calcaneotibial angle increased significantly post-operatively, from 63.77 degrees on average to 70.54 degrees. Intermalleolar height and valgus ankle did not change significantly. Most patients had plantigrade feet after surgery, without pressure ulcers, and were able to use orthoses. CONCLUSION: Westin's tenodesis, with or without other associated procedures, can correct or improve the calcaneus and valgus ankle deformity in patients with myelomeningocele sequelae. There was no association of the surgical result with age at the time of surgery. There was no inversion of the deformity in equinus during the follow-up time.

Hip salvage surgery in cerebral palsy cases: a systematic review.

Imbalance and muscle spasticity, in association with coxa valga and persistent femoral anteversion, compromises hip development in cases of cerebral palsy and may result in chronic pain and even dislocation. Some of these hips undergo salvage surgery because of the severe impact of their abnormalities in these patients' quality of life. We conducted a systematic review of the literature to compare the results from the main hip salvage techniques applied to these individuals. The literature search focused on studies that evaluated results from hip salvage surgery in cases of cerebral palsy, published from 1970 to 2011, which are present in the Embase, Medline, PubMed, Cochrane Library and SciELO databases. Although the results were not statistically comparable, this systematic review demonstrates that hip salvage surgery should be indicated after individual evaluation on each patient, due to the wide spectrum of presentations of cerebral palsy. Therefore, it seems that no surgical technique is superior to any other. Rather, there are different indications.

O desequilíbrio e a espasticidade muscular, associados à coxa valga e à anteversão femoral persistente, comprometem o desenvolvimento do quadril na paralisia cerebral e podem resultar em dor crônica e até luxação. Alguns desses quadris são submetidos a cirurgias de salvamento decorrentes do grave impacto das suas alterações na qualidade de vida. Fizemos uma revisão sistemática da literatura para comparar os resultados das principais técnicas aplicadas para salvamento do quadril nesses indivíduos. A busca na literatura teve como foco estudos que avaliaram resultados de cirurgias de salvamento do quadril em paralisia cerebral, publicados de 1970 a 2011, presentes nas bases de dados Embase, Medline, Pubmed, Scielo e Cochrane Library. Apesar de os resultados obtidos não serem estatisticamente comparáveis, essa revisão sistemática demonstra que as cirurgias de salvamento do quadril devem ser indicadas após avaliação individual de cada paciente, decorrente do amplo espectro de apresentações da paralisia cerebral. Logo, aparentemente, não há uma técnica cirúrgica superior às outras, mas sim indicações diferentes.

Cirurgias de salvamento do quadril em paralisia cerebral: revisão sistemática / Hip salvage surgery in cerebral palsy cases: a systematic review

O desequilíbrio e a espasticidade muscular, associados à coxa valga e à anteversão femoral persistente, comprometem o desenvolvimento do quadril na paralisia cerebral e podem resultar em dor crônica e até luxação. Alguns desses quadris são submetidos a cirurgias de salvamento decorrentes do grave impacto das suas alterações na qualidade de vida. Fizemos uma revisão sistemática da literatura para comparar os resultados das principais técnicas aplicadas para salvamento do quadril nesses indivíduos. A busca na literatura teve como foco estudos que avaliaram resultados de cirurgias de salvamento do quadril em paralisia cerebral, publicados de 1970 a 2011, presentes nas bases de dados Embase, Medline, Pubmed, Scielo e Cochrane Library. Apesar de os resultados obtidos não serem estatisticamente comparáveis, essa revisão sistemática demonstra que as cirurgias de salvamento do quadril devem ser indicadas após avaliação individual de cada paciente, decorrente do amplo espectro de apresentações da paralisia cerebral. Logo, aparentemente, não há uma técnica cirúrgica superior às outras, mas sim indicações diferentes.

Imbalance and muscle spasticity, in association with coxa valga and persistent femoral anteversion, compromises hip development in cases of cerebral palsy and may result in chronic pain and even dislocation. Some of these hips undergo salvage surgery because of the severe impact of their abnormalities in these patients' quality of life. We conducted a systematic review of the literature to compare the results from the main hip salvage techniques applied to these individuals. The literature search focused on studies that evaluated results from hip salvage surgery in cases of cerebral palsy, published from 1970 to 2011, which are present in the Embase, Medline, PubMed, Cochrane Library and SciELO databases. Although the results were not statistically comparable, this systematic review demonstrates that hip salvage surgery should be indicated after individual evaluation on each patient, due to the wide spectrum of presentations of cerebral palsy. Therefore, it seems that no surgical technique is superior to any other. Rather, there are different indications.

Infecções osteoarticulares em Pediatria / Osteoarticular infections in Pediatrics

Os autores reveem definição, incidência e etiologia das infecções osteoarticulares na criança. Analisam o diagnóstico diferencial e o quadro clínico das doenças, bem como os exames laboratoriais e de imagem indicados na suspeita dessa patologia. Com relação ao tratamento, especificam os cuidados a tomar na artrite séptica e na osteomielite, destacando as particularidades da antibioticoterapia e citam o tratamento cirúrgico, assim como os cuidados com o paciente após a regressão do quadro agudo.

Bone age in cerebral palsy.

OBJECTIVE: To compare the chronological age and bone age among cerebral palsy patients in the outpatient clinic and its correlation with the type of neurological involvement, gender and functional status. METHODS: 401 patients with spastic cerebral palsy, and ages ranging from three months to 20 years old, submitted to radiological examination for bone age and analyzed by two independent observers according Greulich & Pyle. RESULTS: In the topographic distribution, there was a significant delay (p<0.005) in tetraparetic (17.7 months), hemiparetic (10.1 months), and diparetic patients (7.9 months). In the hemiparetic group, the mean bone age in the affected side was 96.88 months and the uncompromised side was 101.13 months (p<0.005). Regarding functional status, the ambulatory group showed a delay of 18.73 months in bone age (p<0.005). Comparing bone age between genders, it was observed a greater delay in males (13.59 months) than in females (9.63 months), but not statistically significant (p = 0.54). CONCLUSION: There is a delay in bone age compared to chronological age influenced by the topography of spasticity, functional level and gender in patients with cerebral palsy. Level of Evidence IV, Case Series.

Idade óssea na paralisia cerebral / Bone age in cerebral palsy

OBJETIVOS: Determinar a idade óssea nos pacientes com paralisia cerebral (PC) espástica acompanhados no Ambulatório de Doenças Neuromusculares e comparar com a idade cronológica e correlacionar com os diferentes tipos (hemiparético, diparético, tetraparético), sexo e função motora.MÉTODOS: Analisados 401 pacientes com PC espástica, com idade entre três meses e 20 anos, submetidos a radiografias das mãos e punhos bilaterais e anotado a idade óssea por dois observadores independentes de acordo com o Atlas Greulich & Pyle.RESULTADOS: Quanto a distribuição topográfica, houve um atraso significante (p<0,005) nos tetraparéticos (17,7meses), nos hemiparéticos (10,1 meses) e diparéticos (7,9 meses). No grupo de hemiparéticos, a idade óssea média no lado acometido foi de 96,88 meses e no lado não acometido de 101,13 meses (p<0,005). Em relação ao estado funcional, os não deambuladores demonstraram atraso na idade óssea em relação à idade cronológica de 18,73 meses (p<0,005). Observou-se um maior atraso no sexo masculino (13,59 meses) do que no sexo feminino (9,63 meses), mas não estatisticamente significante (p=0,54).CONCLUSÕES: Há um atraso da idade óssea em relação à idade cronológica influenciado pelo tipo de topografia da espasticidade, nível funcional e sexo na PC. Nível de Evidência IV, Série de Casos.

OBJECTIVE: To compare the chronological age and bone age among cerebral palsy patients in the outpatient clinic and its correlation with the type of neurological involvement, gender and functional status.METHODS: 401 patients with spastic cerebral palsy, and ages ranging from three months to 20 years old, submitted to radiological examination for bone age and analyzed by two independent observers according Greulich & Pyle.RESULTS: In the topographic distribution, there was a significant delay (p<0.005) in tetraparetic (17.7 months), hemiparetic (10.1 months), and diparetic patients (7.9 months). In the hemiparetic group, the mean bone age in the affected side was 96.88 months and the uncompromised side was 101.13 months (p<0.005). Regarding functional status, the ambulatory group showed a delay of 18.73 months in bone age (p<0.005). Comparing bone age between genders, it was observed a greater delay in males (13.59 months) than in females (9.63 months), but not statistically significant (p = 0.54).CONCLUSION: There is a delay in bone age compared to chronological age influenced by the topography of spasticity, functional level and gender in patients with cerebral palsy. Level of Evidence IV, Case Series.

Spinal infections in children: a review.

Spondylodiscitis affects children aged between two and eight years, and mainly involves the lumbar or lumbosacral spine. Diagnosis is difficult because the symptoms are not very specific and due to the children's difficulty in communicating. Unlike adults, children have vascularised intervertebral discs, which explains the higher incidence of this disease in this age group. C-reactive protein, and blood and urine cultures are important laboratory tests. In most cases, fine needle or traditional biopsy helps identify the pathogen particularly in patients who do not respond to the antibiotic therapy test. Magnetic resonance imaging has high sensitivity and specificity in the investigation of pyogenic infection of the spine, particularly in the early stages, when these changes are not shown in other imaging tests. X-rays can take up to six weeks to show changes. The first radiographic sign of infection is the irregularity of the vertebral endplates in the infection area, followed by their erosion and that of the adjacent bone, decreased disc space, segmental collapse, loss of lordosis (in cases of low back involvement) and ultimately, permanent structural deformity. After eight to twelve weeks, local regeneration occurs, accompanied by bone sclerosis arising from the formation of new trabecular bone, replacing the necrotic cancellous bone. Effective treatment often leads to bone fusion of the affected disc space. However, when no therapy is adopted, total vertebral collapse can occur. The treatment involves immobilisation, antibiotic therapy, and surgical decompression in more advanced cases.

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.

Osteocondrite de Van Neck-Odelberg: relato de 4 casos / Van neck-odelberg osteochondritis: report on 4 cases

A osteocondrite de Van Neck-Odelberg é uma doença rara, que acomete a sincondrose isquiopúbica. Foram avaliados quatro crianças em idade escolar com queixa de dor súbita no quadril esquerdo. As radiografias mostravam alteração da sincondrose isquiopúbica. Os casos foram confirmados com ressonância magnética. Todos os casos foram tratados com marcha sem carga no membro acometido por duas a quatro semanas com melhora completa do quadro.

The Van Neck-Odelberg osteochondritis is a rare disease that affects the ischiopubic synchondrosis. We evaluated four school-age children with complaints of acute pain in the left hip. Radiographs showed a change in the ischiopubic synchondrosis. The cases were confirmed with MRI. All cases were treated with walking withno weight bearing on the affected limb for two to four weeks with complete improvement of symptoms.

RESULTS OF ADDUCTORS MUSCLE TENOTOMY IN SPASTIC CEREBRAL PALSY.

OBJECTIVE: Radiographic evaluation of the evolution of hips that underwent soft-tissue release. METHODS: This was a retrospective evaluation on 101 spastic cerebral palsy patients who underwent soft-tissue release between 1991 and 2006. Forty-four patients met the inclusion criteria: 23 boys and 21 girls; 34 diparetic and 10 quadriparetic. Functionally, 29 were non-walkers, five were able to walk at home and 10 were able to walk within the community. Reimers' index (RI) and the acetabular index (AI) were measured on pre and postoperative radiographs, with a minimum follow-up of three years. The mean age at the time of surgery was 6.4 years. RESULTS: The results were considered good if the RI had reduced, or had increased by less than 10%. This was found in 52% of this study. We observed a clear improvement in IR, along with worse results in patients with more than five years of postoperative follow-up. CONCLUSION: Soft-tissue release should be performed as early as possible, regardless of age, walking condition, clinical type, RI, AI or sex, and as soon as the patient clinically presents less than 30° abduction, because of the benefits relating to walking, prevention and treatment of subluxation, hygiene and pain relief.

Resultados da tenotomia dos músculos adutores do quadril na paralisia cerebral espástica / Adductors tenotomy in spastic cerebral palsy

OBJETIVO: Avaliação radiográfica da evolução dos quadris submetidos à liberação de partes moles. MÉTODOS: Avaliação retrospectiva de 101 pacientes com paralisia cerebral submetidos à liberação de partes moles, no período entre 1991 e 2006. Destes, 44 pacientes com critérios de inclusão, 23 do sexo masculino e 21 do feminino, 34 diparéticos e 10 tetraparéticos. Funcionalmente, 29 não andadores, cinco andadores domiciliares e 10 andadores comunitários. Foram mensurados o índice acetabular (IA) e índice de Reimers (IR) nas radiografias pré e pós-operatória, com tempo mínimo de seguimento de três anos. A idade média na cirurgia foi 6,4 anos. RESULTADOS: Considerou-se bom resultado os quadris com diminuição ou aumento menor que 10 por cento do IR (52 por cento deste estudo). Observou-se melhora evidente do IR, além de apresentar piores resultados nos pacientes maiores de cinco anos de seguimento pós-operatório. CONCLUSÃO: Deve-se realizar a liberação de partes moles, o mais precocemente possível, independentemente da idade, condição deambulatória, tipo clínico, IR, IA e sexo, assim que apresentar abdução menor que 30 graus clinicamente, devido aos benefícios quanto à marcha, prevenção e tratamento da subluxação, higienização e alívio da dor.

OBJETIVE: Radiographic evaluation of the evolution of hips that underwent soft-tissue release. METHODS: Retrospective study of 101 spastic Cerebral Palsy patients who underwent soft-tissue release between 1991 and 2006. Forty-four patients met the inclusion criteria, 23 boys and 21 girls, 34 diparetic and 10 quadriparetic. Twenty-nine were non-ambulatory, 5 were ambulatory domestically and 10 ambulatory. Reimers' index (RI) and the acetabular index (AI) were measured, pre- and post-operatively, with a minimum follow-up of 3 years. The mean age at the time of surgery was 6.4 years. RESULTS: Results were considered good if the RI was reduced or had increased less than 10 percent. Results were good for 52 percent of this study. We observed a clear improvement of IR, in addition to presenting the worst results, in patients older than five years in follow-up. CONCLUSION: Soft-tissues releases should be done as soon as the patient clinically presents less than 30º of hip abduction, regardless the age, level of functioning, clinical type, RI, AI and sex, to help patients in the prevention and treatment of the subluxation, hygiene, and pain relief.

Tríplice artrodese na paralisia cerebral / Triple arthrodesis in cerebral palsy

OBJETIVOS: Avaliar o resultados clínicos díplice artrodese em portadores de paralisia cerebral espástica, verificar a correspondência entre os resultados e a escala AOFAS e os ângulos nos períodos pré e pós-operatórios. MÉTODOS: Entre 1985 e 2005, foram avaliados 34 pacientes (40 pés) submetidos a tríplice artrodese do pé, com acompanhamento médio de 91 meses, quanto a satisfação e dor, apoio plantígrado, deformidade residual e o arco de movimento do tornozelo e escala AOFAS. Foram avaliadas artrose de tornozelo, pseudoartrose das articulações e medidos os ângulos: talocalcâneo, talo-primeiro metatarsiano (APM) e tíbio-talar, e talocalcâneos (ATC) e o calcâneo-solo (ACS). RESULTADOS: Obtivemos bons resultados em 32,4 por cento dos casos e regulares em 44,1 por cento. 85,3 por cento dos pacientes estavam satisfeitos; 88,2 por cento tinham apoio plantígrado. Houve 33,3 por cento de resultados bons pela escala AOFAS e 24,2 por cento regulares. Na radiografia com incidência ântero-posterior, o APM apresentou melhora em média de 15º; no ACS, na incidência em perfil, melhora de 7º. No ATC, nas duas incidências, houve melhora de 1º. CONCLUSÕES: A triplice artrodese corrige ou melhora as deformidades, com grau de satisfação elevada, dando ao paciente pés plantígrados. A escala AOFAS teve fraca concordância com o resultado. Os APM e ACS foram os mais sensíveis na avaliação do procedimento cirúrgico.

OBJECTIVE: To demonstrate the clinical results of triple arthrodesis in Cerebral Palsy patients and determine whether there is any correspondence between the results and the AOFAS scale, and changes in radiographic angles between the pre- and postoperative periods. METHODS: Between 1985 and 2005, thirty-four patients (40 feet) were submitted to triple arthrodesis of the foot, with an average follow-up time of ninety-one months. The evaluation consisted of the patient's satisfaction and the presence of pain, plantigrade support, residual deformity, range of movement of the ankle, and the AOFAS. Radiographs were made of the foot and ankle to assess the presence of ankle arthrosis, pseudarthrosis of the joints, and measurements of the following angles: talocalcaneal, talur-first metatarsal and tibiotalar, and talocalcaneal and calcaneal pitch. RESULTS: The results were good in 32.4 percent of cases, regular in 44.1 percent, satisfactory in 85.3 percent and 88.2 percent had plantigrade support. With the AOFAS scale, the results were good in 33.3 percent and regular in 24.2 percent. In the radiogra-phic assessment, the AP talar-first metatarsal angle showed an average improvement of 15º, the LAT calcaneous pitch improved by 7º. The talocalcaneal angles, both AP and LAT, improved in 1º. CONCLUSIONS: This study concluded that the triple arthrodesis corrects or improves these deformities; the patient showed a high level of satisfaction, most of them with a plantigrade foot. The AOFAS scale had low correlation with the result. The talur-first metatarsal and calcaneal pitch were the most sensitive in the evaluation of the surgical procedure.

Efeitos no tornozelo da mielomeningocele pós-tenodese de Westin / Effects of myelomeningocele in the ankle after Westin tenodesis

OBJETIVO: Avaliar o aumento do crescimento fibular em pacientes portadores de seqüela da mielomeningocele com deformidades em pé calcâneo e valgismo do tornozelo submetidos à tenodese de Westin. MÉTODOS: O estudo avaliou seis pacientes (12 pés) portadores de seqüela de mielomeningocele, deambuladores comunitários, submetidos à tenodese do calcâneo na fíbula com pontos transósseos, seguindo a técnica originalmente descrita por Westin, no período de janeiro de 1996 a dezembro de 2000. RESULTADOS: A análise dos resultados da diferença de altura intermaleolar em pacientes com seqüela de mielomeningocele apresentando deformidade tipo pé calcâneo, submetidos ao tratamento cirúrgico com tenodese do calcâneo pela técnica de Westin, evidenciou crescimento do maléolo lateral importante quando comparado com as medidas pré-operatórias (p < 0,05). Os resultados mostram também que o crescimento do maléolo lateral não está relacionado com a idade em que o paciente foi submetido ao tratamento cirúrgico; todos os seis pacientes apresentaram padrões de crescimento diferentes no decorrer do seguimento pós-operatório. Quando se avaliou a correção do ângulo valgo do tornozelo, encontrou-se diminuição do mesmo com correção parcial ou total da deformidade (p < 0,05). CONCLUSÃO: Os resultados mostram que também ocorre o crescimento do maléolo lateral na tenodese do calcâneo pela técnica de Westin em pacientes com seqüela de mielomeningocele devido ao estímulo de crescimento do próprio tendão na fíbula. Porém, esse crescimento não apresenta relação com a idade em que o paciente foi submetido ao procedimento cirúrgico. Houve concomitante correção da angulação em valgo do tornozelo.

OBJECTIVE: To evaluate the increased fibular growth in patients with myelomeningocele sequelae with deformities in calcaneus foot and ankle valgus submitted to Westin tenodesis. METHODS: The study evaluated six patients (12 feet) with myelomeningocele sequelae, ambulant, submitted to tenodesis of the calcaneus tendon in the fibula, with transbone stitches following the technique that was originally described by Westin, from January 1996 to December 2000. RESULTS: Analysis of the results of the intermaleolar height difference presenting calcaneus foot deformity and submitted to surgical treatment with calcaneus tendon tenodesis according to the Westin technique showed a major growth of the lateral malleolus when compared to pre-operative measurements (p < 0.05). Results also show that the lateral malleolus growth is not related to the patient age when he or she was submitted to surgery. All of the six patients presented different growth patterns along the follow-up. When the authors evaluated the correction of the valgus angle in the ankle, they found a decrease of the angle, with partial or total correction of the deformity (p < 0.05). CONCLUSION: Results show that growth of the lateral malleolus does occur in calcaneus tendon tenodesis following the Westin technique in patients with myelomeningocele sequelae due to the growth stimulus of the tendon in the fibula. However, such growth is not related to the age in which the patient was submitted to surgery. There was a concomitant correction of the valgus angle of the ankle joint.