RESUMO

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.

RESUMO

Amniotic band syndrome (ABS) and clubfoot are distinct congenital musculoskeletal conditions that can occasionally co-occur, creating unique challenges in their management. This paper summarizes the comprehensive discussion on the management of amniotic band syndrome (ABS) and clubfoot, emphasizing the critical role of the Ponseti method and the challenges faced in treatment, thereby providing a basis for further research and improved patient care.

El síndrome de banda amniótica (ABS) y el pie zambo son afecciones musculoesqueléticas congénitas distintas que ocasionalmente pueden coexistir, creando desafíos únicos en su manejo. Este artículo resume la discusión exhaustiva sobre el tratamiento del síndrome de bandas amnióticas (ABS) y el pie zambo, enfatizando el papel fundamental del método Ponseti y los desafíos que enfrenta el tratamiento, proporcionando así una base para futuras investigaciones y una mejor atención al paciente.

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RESUMO

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.

RESUMO

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.

RESUMO

ABSTRACT 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.

RESUMO 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.

RESUMO

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.

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Abstract: Complex clubfoot is a term used to describe a subset of patients that received previous treatment, and have distinctive anatomical features: severe equinus, with short first metatarsal, hyperextended big toe, severe plantar flexion of all metatarsals and deep folds through the sole of the foot and above the heel. Most complex clubfeet appear to be idiopathic and is usually associated with a poor casting technique. Complex clubfoot requires an early recognition and an adjustment of the casting protocol using the four finger Ponseti technique. This article gives the treating physician a general overview of the evaluation, treatment, and outcomes of complex clubfoot with the Ponseti method.

Resumen: El pie equinovaro complejo es un término utilizado para describir un subconjunto de pacientes que recibieron tratamiento previo y tienen características anatómicas distintivas: equino severo, con primer metatarsiano corto, dedo gordo hiperextendido, flexión plantar severa de todos los metatarsianos y pliegues profundos en la planta del pie y por encima del talón. Los pies equinovaros más complejos parecen ser idiopáticos y generalmente se asocian con una mala técnica de yeso. El pie equinovaro complejo requiere un reconocimiento temprano y un ajuste del protocolo de yeso utilizando la técnica de Ponseti de cuatro dedos. Este artículo le brinda al médico tratante una descripción general de la evaluación, el tratamiento y los resultados del pie equinovaro complejo con el método Ponseti.

RESUMO

Congenital clubfoot is one of the most common congenital deformities of the lower limbs, with an estimated incidence of 1 for every 1,000 live births. Its treatment is controversial, and currently the Ponseti method has been widespread, showing promising results and decreasing the need for extensive surgical releases, as was usually done until the introduction of the technique. Currently used in approximately 55 countries, the method has changes and scopes that vary according to the society in which it is applied, with the results and peculiarities of the method molded according to the sample studied. Objective: To evaluate the clinical outcome of clubfoot treatment using the Ponseti method under local conditions. Methods: The clinical evaluation will include a descriptive analysis of the sample, as well as radiographic evaluation and family satisfaction with the treatment. Results: In total, 46% of the patients had good results and no family was dissatisfied with the treatment results. No statistically relevant relationships were found between the studied variables. Conclusion: The results are good and generally similar to those in the literature. Our epidemiological data generally agree with those reported by other authors. Level of Evidence IV, Case Series.

O pé torto congênito (PTC) é uma das deformidades congênitas mais comuns dos membros inferiores, com incidência estimada de um para cada 1.000 nascidos vivos. Seu tratamento é motivo de controvérsia, mas, atualmente, o método de Ponseti tem sido difundido, mostrando resultados promissores e diminuindo a necessidade das liberações cirúrgicas extensas, como geralmente se fazia até a introdução da técnica. Utilizado em aproximadamente 55 países, o método apresenta alterações e alcances que variam de acordo com a comunidade em que é aplicado, sendo o resultado e as peculiaridades do método moldados de acordo com a amostra estudada. Objetivo: Avaliar o resultado clínico do tratamento do PTC através do método de Ponseti em condições locais. Métodos: A avaliação clínica incluiu uma análise descritiva da amostra, além de avaliação radiográfica e satisfação da família com o tratamento. Resultados: 46% dos pacientes apresentaram bons resultados e nenhuma família se mostrou insatisfeita. Não foram encontradas relações estatisticamente relevantes entre as variáveis estudadas. Conclusão: Os resultados são bons e, de maneira geral, semelhantes àqueles da literatura. Há, também, concordância geral dos dados epidemiológicos deste estudo com os relatados por outros autores. Nível de Evidência IV, Série de Casos.

RESUMO

INTRODUCTION: Early intervention is essential for proper foot growth in postural congenital clubfoot (PCC), but little is known about its contribution to this deformity when subjects are evaluated through telemonitoring. OBJECTIVE: This study aimed to monitor the foot's flexibility of newborns diagnosed with PCC by telemonitoring them during the first months of life. METHODS: A longitudinal descriptive study was carried out with a full-term newborns group diagnosed with PCC in at least one limb, presenting a grade ≥ 0,5 on the Pirani score. Newborns with other malformations were excluded. They were assessed twice: before and 30 days after hospital discharge, and the foot flexibility classification by the Pirani score was provided. The telemonitoring occurred weekly between the assessments, and the parents were encouraged to mobilize their feet and maintain foot position using orthosis or taping. RESULTS: Thirteen newborns (eighteen feet) presenting PCC were included in this study; seven neonates discontinued the study due to absences from pre-scheduled evaluations, and six were telemonitored for 30 days. They were born at 39 weeks (± 1.18) and 3346.54 g (± 306.51). The majority of the newborns were female (69%), one was born vaginally, and eight (61%) had a family history of PCC. Pirani's score ranged from 1 to 3 in the initial assessment. After one month of telemonitoring, three feet progressed to 0, and four feet scored between 0.5 and 1. CONCLUSION: This study shows an important improvement in the foot's flexibility of newborns diagnosed with PCC evaluated through telemonitoring. Telemonitoring may be an additional resource for assisting newborns with PCC.

INTRODUÇÃO: A intervenção precoce é essencial para o correto crescimento do pé torto congênito postural (PTC), mas pouco se sabe sobre sua contribuição para essa deformidade quando os pacientes são avaliados por meio de telemonitoramento. OBJETIVO: Este estudo teve como objetivo acompanhar, por telemonitoramento, a flexibilidade do pé de recém-nascidos com diagnóstico de PTC durante os primeiros meses de vida. MÉTODOS: Foi realizado um estudo descritivo longitudinal com recém-nascidos a termo, diagnosticados com PTC em pelo menos um pé, apresentando escore de Pirani ≥ 0,5. Foram excluídos recém-nascidos com outras malformações. Os recém-nascidos foram avaliados nas primeiras horas de vida e 30 dias após a alta hospitalar. Durante este período os pais foram incentivados a mobilizar os pés diariamente e manter a posição por meio de órtese ou bandagem. O telemonitoramento ocorreu semanalmente, e a flexibilidade dos pés foi classificada pelo escore de Pirani. RESULTADOS: Foram incluídos neste estudo treze recém-nascidos (dezoito pés), sete descontinuaram o estudo por faltas nas tentativas de contato e seis foram telemonitorados por 30 dias. A maioria dos RN era do sexo feminino (69%), nasceram com 39 semanas (± 1,18) e 3.346,54g (± 306,51). Um nasceu de parto normal e oito (61%) tinham histórico familiar de PTC. Inicialmente, a pontuação de Pirani variou de 1 a 3. Após 30 dias de telemonitoramento, três pés evoluíram para 0 e quatro pontuaram entre 0,5 e 1. CONCLUSÃO: Este estudo mostra uma melhora importante na flexibilidade do pé de recém-nascidos com diagnóstico de PTC, avaliados por telemonitoramento. O telemonitoramento pode ser um recurso adicional para assistência ao recém-nascido com PTC.

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INTRODUCTION: our aim was to evaluate the clinical outcomes and complications of anterior tibialis tendon transfer (ATTT) in children with dynamic supination after clubfoot treatment. MATERIAL AND METHODS: children with dynamic supination after initial treatment with Ponseti method or surgery who underwent ATTT between 2008 and 2020 were included for evaluation. Demographic data, previous treatment, associated procedures and fixation method were analyzed. Functional results were evaluated with the grading system described by Thompson. Complications and their treatment were analyzed. RESULTS: a total of 39 patients (57 feet) were analyzed. 70% received previous treatment with Ponseti method, 19.3% underwent surgical posteromedial release, and 10.7% another type of surgical treatment. 88% of cases required associated procedures including Achilles tendon lengthening or tenotomy, plantar fasciotomy, tibial osteotomy, lateral column shortening, posterior release. The predominant type of fixation was the pull-out button method (96.5%). The average follow-up was 31.5 months. According to the Thompson grading system, 52 patients presented good results, two fair and three poor. 98.2% of the feet showed active contraction of the transferred tibialis anterior tendon. There were four complications: plantar irritation, synovial cyst in the dorsum of the foot and deep infection. Two feet required unplanned surgery. CONCLUSION: anterior tibialis tendon transfer is an effective technique to correct residual dynamic supination in patients with clubfoot.

INTRODUCCIÓN: el objetivo de este estudio fue evaluar los resultados clínicos y complicaciones de la transferencia del tendón tibial anterior (TTTA) en niños con pie bot y supinación dinámica. MATERIAL Y MÉTODOS: se incluyeron niños con recurrencia dinámica del pie bot después de tratamiento con método Ponseti o cirugía, que se sometieron a TTTA entre 2008 y 2020. Se analizaron datos demográficos, tratamientos previos, procedimientos asociados y método de fijación. Los resultados funcionales fueron evaluados con el sistema de graduación descrito por Thompson. Se analizaron las complicaciones y su tratamiento. RESULTADOS: se analizaron 39 pacientes (57 pies). Setenta por ciento recibió tratamiento previo con método Ponseti, a 19.3% se le realizó liberación posteromedial y a 10.7% otro tipo de tratamiento quirúrgico. Ochenta y ocho por ciento de los casos requirió procedimientos asociados: tenotomía o alargamiento del tendón de Aquiles, fasciotomía plantar, osteotomía desrotadora de tibia, acortamiento de columna lateral, liberación posterior. El tipo de fijación predominante fue pull-out con botón (96.5%). El seguimiento promedio fue de 31.5 meses. De acuerdo al sistema de Thompson, 52 pacientes presentaron resultados buenos, dos regulares y tres malos. 98.2% de los pies mostraron contracción activa del tendón del tibial anterior transferido. Se presentaron cuatro complicaciones: irritación plantar, quiste sinovial en dorso e infección profunda. Dos pies requirieron cirugía no programada. CONCLUSIÓN: la transferencia del tendón del tibial anterior es una técnica eficaz para corregir la supinación dinámica residual en pacientes con pie bot.

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