bluuebunny/crossref_metadata_2025 huggingface dataset:
PO 18191 - Congenital distal tibiofibular diastasis
Authors: Maria Pereira Jordanna , Cardenuto Ferreira Ricardo , Tulio Costa Marco , De Marchi Neto Noé , Kerry Gobbo Daiana , Cursino Fernandes Milena Peloggia
Published: November 2019

Introduction: Congenital distal tibiofibular diastasis is an extremely rare entity of unknown etiology that compromises the feet and ankles with different degrees of deformity, although in general, the feet show equinovarus deformity, and the talus is proximally dislocated due to the separation of the distal tibial and fibular epiphyses. There are few reports of this disorder in the literature, and most describe cases that ultimately lead to limb amputation. We present the cases of 2 patients treated from birth to skeletal maturity. Methods: Two female patients with clubfoot at birth were diagnosed with congenital distal tibiofibular diastasis. One of them had the deformity of the right foot, and the other had deformity of both limbs. Both patients underwent early distal tibiofibular arthrodesis and serial stretching of the compromised feet and legs. Results: After 20 years of clinical follow-up and after reaching skeletal maturity, both patients had plantigrade feet without significant shortening of the lower limbs or pain, and both performed activities of daily living without restrictions, wearing conventional shoes. Conclusion: Early distal tibiofibular arthrodesis followed by limb stretching was effective for treating congenital distal tibiofibular diastasis and is a good alternative to amputation, which is indicated in the literature.
PO 18195 - Publication trends of research on hallux valgus (1998 - 2018)
Authors: Cristina Stéfani Kelly , Ferraz Ferreira Gabriel , Quadros Borges Vinicius , De Matos Moraes Leonardo Vinícius
Published: November 2019

Introduction: Hallux valgus (HV) is a very common deformity among affections of the foot, and interest in the subject is persistent in the daily routine of orthopedic surgeons. We investigated the trend in HV publications in the literature. Methods: The research was carried out by searching the Web of Science database between 1998 - 2018, analyzed using a bibliometric methodology. We used the "Bibliometrix" package for R software for the data compilation and VOSviewer for graphic creation. Results: A total of 703 articles were found from the electronic search until December 21, 2018, with 6266 citations. The major scholar in this field was Coughlin M.J., with the largest number of publications (17). The United States led in number of articles published with 26.74%, with Brazil ranked in 26 place. There was an increase in the number of publications, with the highest number of articles published in 2016 (78). Conclusion: The amount of published work on HV has grown rapidly since 2011. The United States has the leading position in global research. The journal with more articles was Foot and Ankle International.
PO 18197 - PROMO technique for hallux valgus treatment
Authors: Garreta Prats Dias Celso , De Souza Nery Caio Augusto , Kerber Cavalcanti Lemos Andre Vitor
Published: November 2019

Introduction: Hallux valgus (HV) deformity is a prevalent condition that affects several aspects of the foot, causing pain, imbalance, immobility and increased risk of falls. Various osteotomies have been described for HV treatment, and osteotomy is the best option currently available among hundreds of surgical techniques, although no osteotomy is considered better than any other. The incidence of complications is associated with the degree of deformity, which may be defined according to the HV angle, the intermetatarsal angle and the degree of sesamoid subluxation. When the deformity is diagnosed as severe, the risk of recurrence is higher. Wagner et al. (2017) focused on controlling these complex cases and described a technique called Proximal ROtational Metatarsal Osteotomy (PROMO), inspired by the rotational osteotomy for Blount’s disease. Objective: To present the outcomes of 10 cases of severe HV (16 feet) treated using the PROMO technique. Methods: The pre- and postoperative data of 16 consecutive patients treated at a private hospital in São Paulo, SP, were collected. All patients were treated using the PROMO technique described by Wagner et al., and radiographs were taken to measure the parameters and collect records. A calculator programed in Microsoft Excel®, together with a cell phone application, were used to calculate the target angle correction power and osteotomy angle according to a process is described in this study. Results: There was satisfactory improvement in the American Orthopedic Foot and Ankle Society (AOFAS) score and subjective pain in all cases, in addition to a clear resolution of the deformity on physical examination and on radiographs. The union time; complications, such as symptomatic or asymptomatic pseudarthrosis; and angle correction power are also described in the present study. Conclusion: The PROMO technique is a safe and interesting option for the treatment of severe HV that has low rates of complications and a high angle correction power.
PO 18204 - Posterior ankle arthroscopy for percutaneous fixation of a posterior malleolar fracture
Authors: De Souza Fernandes Guilherme , Velleca e Silva Claudio
Published: November 2019

Introduction: The authors report the case of a 47-year-old patient who fell and experienced a sprained ankle that progressed to posterolateral fracture-dislocation of the ankle and Lauge-Hansen stage 4 supination-external rotation. Objective: To evaluate the use of posterior ankle endoscopy to facilitate the internal fixation of a posterior malleolar fracture.  Methods: Case report of a patient with posterolateral fracture-dislocation of the ankle and description of the use of endoscopy for treatment. Examinations performed in the emergency room showed evidence of posterior malleolar fracture with a typical Volkmann fragment and a Danis-Weber type-B lateral malleolar fracture with posterolateral dislocation of the ankle joint. After fracture immobilization, the patient underwent surgical treatment with posterior endoscopy of the ankle for visualization and for percutaneous fixation of the posterior malleolar fracture and open reduction, with internal fixation with a direct incision of the fibula (lateral malleolus). Results: The use of endoscopic and arthroscopic methods for the ankle has gained popularity, although there is still apprehension in using posterior endoscopy due to its limited visualization and less-comprehensive indication compared with anterior methods. Currently, posterior methods are indicated for osteochondral lesions of the subtalar joint, posterior malleolar and calcaneal fractures, tenosynovitis of the flexor hallucis longus and posterior synovitis. Despite the limited visualization, the use of endoscopy in this case enabled the percutaneous reduction and fixation of the posterior malleolus without requiring a classic posterior approach; consequently, the patient experienced less pain during the postoperative period and faster recovery than occurs with the classic incision. Conclusion: We expect that over time posterior endoscopy will be increasingly used among surgeons in cases of posterior malleolar fracture because it offers a shorter hospital stay and allows patients to resume their activities of daily living earlier. However, posterior endoscopy of the ankle is not without complications and has a steeper learning curve than anterior endoscopy. Therefore, knowledge of the anatomy, indications and technique is fundamental.
PO 18216 - Ultrasound evaluation of the tibial nerve in leprosy patients
Authors: De Schoucair Jambeiro Jorge Eduardo , Tavare Cordeiro Neto Antero , Delmonte Moreira Fernando , De Oliveira José Augusto , Hohlenwerger Barral Victor , Anunciação Mendes Adriana
Published: November 2019

Introduction: Brazil is the second country in the world in cases of leprosy. Early diagnosis of neural involvement is one of the most important goals of treatment. Traditionally, clinical examination is used for diagnosis; however clinical palpation has limitations that can lead to a delay of diagnosis. Ultrasonography (USG) provides objective measurements of neural thickening. The most important parameter in the USG is the cross-sectional area (CSA) of the nerve. To our knowledge, studies evaluating leprosy of the tibial nerve through the USG have not yet been performed. This work aims to analyze USG as a method of evaluation of the posterior tibial nerve in leprosy patients. Methods: This is a nonrandomized, prospective study in patients with leprosy of the tibial nerve, comparing the findings of the USG performed with clinical data for these patients. Results: Sixteen tibial nerves were evaluated in 8 patients, with a mean age of 53.4 years; the highest CSA was 24.6 mm2 with an average of 15.0 mm2, 75% had sensitivity alterations, 33.3% had anesthesia, 16.7% had loss of deep sensitivity, 25% had loss of protective sensitivity and another 25% had decreased sensitivity. Clinically, 25% of the patients had claw toe and 18.75% plantar ulcer. Discussion: USG demonstrated increased CSA of the tibial nerve in 87.5% of the cases; there was considerable variation in CSA size for patients with thickening palpation, which could represent different levels of neural involvement for the same clinical finding. We observed a greater loss of sensation in patients with higher CSA of the tibial nerve, as well as the presence of claw toe and plantar ulcer. Conclusion: USG is a suitable method for assessing neural thickening in leprosy patients. Other studies are necessary for a better correlation of CTA with clinical data and the determination of clinical conducts.
TL 18086 - Forefoot axial radiographic study for the evaluation of metatarsal head alignment in the coronal plane
Authors: Sposeto Rafael Barban , Fernandes Tulio Diniz , Sakaki Marcos Hideyo , Godoy-Santos Alexandre Leme , Ortiz Rafael Trevisan , Corsato Marcos Andrade
Published: November 2019

Introduction: Many authors consider differences in the relative length of metatarsal bones in the axial plane a cause of inadequate load distribution during gait, leading to metatarsalgia. The goal of surgical treatment is to realign the metatarsal formula. However, many studies have shown a 15% metatarsalgia recurrence rate after reconstructing the advocated metatarsal formula in the axial plane, questioning the importance of the alignment of the metatarsal heads in the coronal plane.  Objective: To evaluate the alignment pattern of the metatarsal heads in the coronal plane in individuals with and without metatarsalgia. Methods: This cross-sectional study evaluated individuals aged 30 to 65 years, dividing them into 2 groups, one without foot pain, deformities or callosities and another with metatarsalgia between the 2nd, 3rd and 4th metatarsal bones. The individuals were selected according to inclusion and exclusion criteria and were included in the study after signing an informed consent form. After the selection, the subjects underwent one weight-bearing forefoot axial radiograph evaluating the coronal plane to measure the heights of the metatarsal heads and a weight-bearing anteroposterior foot radiograph to determine the length of each ray. Statistical analysis was performed to compare the measurements of the 2 groups.  Results: In total, 106 individuals were divided into 2 groups, each comprising 106 feet, and evaluated. In the group with metatarsalgia, 32% patients were men, the mean age was 49.5 years, and 33 feet had hallux valgus. In the group without metatarsalgia, 51% patients were male, and the mean age was 44.6 years. The measured anthropometric variables did not differ significantly between groups. In both groups, the metatarsal heads were distributed in a curved line in the coronal plane, following the formula M1M3>M4=M5. The distal support of the 1st ray was in a more plantar position in the group of patients with metatarsalgia (p=0.000).  Conclusion: The metatarsal heads of the individuals of both groups were aligned in the coronal plane following the formula M1M3>M4=M5. However, M1, M4 and M5 were at the same height in the group without metatarsalgia, whereas the M1 weight-bearing point was more plantar in the feet of patients with metatarsalgia.
TL 18091 - Risk in the sinus tarsi approach
Authors: Heitzmann Lourenço Galizia , Molina Wellington Farias , Martins Guilherme Bottino , Pimenta Luiz Sergio Martins , Alvo Fernando Salgueiro , Capellasso Bruno Augusto Mendonça
Published: November 2019

Objetivo: To evaluate the topographic and morphometric aspects of the sural nerve in cadavers as well as its relationship with the modified Palmer approach.  Methods: Thirty lower limbs of fifteen fresh cadavers were used for dissection of the sural nerve, and 5 measurements were performed using the lateral malleolus and the calcaneal tendon as the repair point. The paired student's T-test was used to compare the averages of the measurements between the sides of the same cadaver. A value of p < 0.05 was considered significant for all analyses.  Results: On average, the sural nerve issued its first branch 40.40 mm above the lateral malleolus, situated on average 13.84 mm posterior to the tip of the lateral malleolus and on average 23.76 mm inferior to the point of the lateral malleolus.  Conclusion: The modified Palmer’s approach was shown to be promising, since it demonstrated lower postoperative complication rates, especially when compared with the extended lateral pathway. The results obtained will aid during the surgical incision, adding safety to the procedure by avoiding injury of branches of the sural nerve.
PO 18238 - Floating metatarsal associated with comminuted calcaneocuboid joint fracture and turf toe
Authors: Rodrigues de Miranda Bruno , Dos Santos Barroco Rui , Prates de Oliveira Leticia Zaccaria , Beerens Abdul Ghani Abdul Ghani Mahmoud , Candido de Paula Neto Antonio , Hideki Ikeuti Douglas
Published: November 2019

Introduction: The term “floating metatarsal” refers to a rare injury pattern characterized by metatarsal dislocation in both the Lisfranc and metatarsophalangeal joints. The term “turf toe” refers to the rupture of the plantar capsular-ligamentous complex of the first metatarsophalangeal joint. Objective: To report a rare case of floating metatarsal associated with turf toe and comminuted calcaneocuboid joint fracture causing a midfoot abduction deformity. Method: To report the case of a patient who suffered a motorcycle accident and progressed with this rare combination of associated injuries. Results: The patient underwent surgical cleaning, reconstruction of the plantar capsular-ligamentous injury and reduction with Kirschner wire fixation of the first metatarsal and calcaneal fracture, with a local graft for lateral column and calcaneocuboid joint lengthening. The patient progressed well in the 18-month follow-up; fracture union and good joint stability with a slight limitation in range of motion were achieved. Discussion: Floating metatarsal is an injury poorly described in the literature, and its association with turf toe is due to trauma with metatarsophalangeal hyperextension. The patient may postoperatively develop postraumatically acquired hallux rigidus and hallux valgus. Conclusion: The identification of these injuries and a good clinical evaluation are crucial for adequate treatment and the prevention of possible complications.
PO 18239 - Malerba Z-type osteotomy for the treatment of adult acquired flatfoot deformity
Authors: Barbachan Mansur Nacime Salomão , Furtado da Fonseca Lucas , Kerber Cavalcante Lemos André Vitor , Felipe Pereira Vinicius , Garreta Parts Dias Celso , Souza Nery Caio Augusto
Published: November 2019

Introduction: Adult acquired flat foot deformity (AAFD) is a condition characterized by tendon and ligament failure that leads to progressive midfoot collapse and to hindfoot valgus. Calcaneal osteotomies are among the oldest and most conventional procedures for the treatment of angular limb deformities; they aim to reestablish the alignment and the line of action vector of the triceps surae muscle. Various disadvantages of classic osteotomies have been established in recent years, such as fixation loss, insufficient correction and reduced tarsal tunnel volume. Malerba Z-type osteotomy aims to resolve possible complications resulting from the usual incisions, to enhance the procedure and to allow multiplane corrections. Objective: To describe the functional and radiographic outcomes of Malerba Z-type osteotomy in patients with AAFD subjected to reconstructive surgery. Methods: Ten patients diagnosed with AAFD, with a mean age of 45 years (35-55), were operated on from January 2017 to January 2018. All patients underwent weight-bearing radiographs and alignment measurements and functional assessment using the pain visual analog scale (VAS) and the American Orthopedic Foot and Ankle Society (AOFAS) scale preoperatively and at the final evaluation at a mean of 12 months (6-18 months) after surgery. Results: The 10 patients showed positive progression after the surgery, reporting no major complications. Only one case of superficial dehiscence and one case of transient sural nerve neuropraxia (in different patients) were observed. On average, the AOFAS score increased by 50 points on average (25.7 to 76.6), and the VAS score decreased by 4 points (8.3 to 3.4). The mean calcaneal pitch increased from 5.5° to 15.2°. Nine patients transitioned from valgus malalignment (hindfoot angle greater than 10°) to the physiological (5 to 10° valgus) range. Conclusion: Ankle-foot realignment is an essential condition for surgical success in AAFD; it promotes a soft-tissue healing environment while maintaining an adequate muscle line of action. Malerba Z-type osteotomy was found to be a safe technique with high potential for deformity correction, leading to functional and radiographic improvement in patients who undergo this surgery.
PO 18244 - Arthroscopic subtalar arthrodesis in tarsal coalition
Authors: Vieira da Fonseca Wagner , De Andrade Gomes Rogério , Coelho Byrro Oliveira Gilberto , Max e Silva Sidney , Maciel Vilela Matheus , Janotti Pádua Bruno
Published: November 2019

Objective: To describe the technique and results of arthroscopic arthrodesis through lateral portals in clinical cases of medial subtalar coalition. The posterior arthroscopic technique is considered the most difficult method for coalition resection. Methods: Five patients were operated on from April 2015 to July 2018, a study period of approximately 2 years and 3 months. The patients’ age ranged from 37 years and 6 months to 58 years and 1 month, with a mean age of 44 years and 5 months. All patients were operated on through 2 lateral portals using an eyepiece and knee and shoulder arthroscopic surgery instruments, and fixation was performed using 6.5- and 7.0-mm screws. The use of osteotomes was combined with curettes for coalition osteotomy and fusion release. An accessory lateral posterior portal was also used in one patient. Results: The patients were evaluated at 1, 2, 4 and 6 weeks and subsequently at 3 months, when computed tomography was performed to confirm the fusion. The final evaluations were performed at 6 months and 1 year. At the initial evaluation, the mean American Orthopedic Foot and Ankle Society Score (AOFAS) score was 56.7 points preoperatively; it increased to 87.4 after the blocked inversion/eversion was addressed through arthrodesis. Conclusion: This coalition osteotomy and curettage technique involving the release of the blocked subtalar motion to achieve fusion of the posterior, anterior and medial portions of the subtalar joint was found to be feasible through arthroscopic lateral portals. We recommend this procedure as long as no valgus deformity or significant abduction is present.
PO 18251 - Functional clinical outcome of the conservative treatment of calcaneal fractures in patients with diabetic neuropathy
Authors: Diniz Freitas Claudia , Araújo Pires Eduardo , Roncatto Carlos Eduardo , Lima Santin Roberto Attílio
Published: November 2019

Introduction: Calcaneal fractures are potentially serious in diabetic patients with foot insensitivity. The consensus is that surgical treatment involves a high risk of complications in these cases, and conservative treatment is the option of choice because it allows monitoring of the onset of pressure ulcers and the degree of hindfoot collapse, which usually occurs as Charcot arthropathy progresses. Objective: To retrospectively evaluate the mid-term functional clinical outcome of conservative treatment of calcaneal fractures in diabetic patients with advanced peripheral neuropathy associated with loss of protective foot sensitivity. Methods: Fifteen patients (16 feet), 12 men and 3 women, whose mean age at the time of the calcaneal fracture was 53 years (ranging from 34 to 70 years) were retrospectively evaluated after conservative treatment with total contact casting. We considered a functional clinical outcome good when the foot was plantigrade and ulcer-free and the patient could wear deep footwear with custom-made insoles for insensitive feet. The outcome was considered acceptable when the patient had residual deformity requiring custom-made polypropylene ankle-foot orthosis (AFO) braces. The outcome was considered poor when extremity amputation was required, when the patient was unable to bear weight on the foot during gait due to hindfoot instability as a result of the fracture, or when the patient showed recurrent ulcer due to bone prominence resulting from fracture malunion. Results: After a mean follow-up time of 40 months (ranging from 12 to 168 months), we assessed a good outcome in 10 feet, an acceptable outcome in 2 feet with braceable residual deformity, and a poor outcome in 4 feet, 3 of which had recurrent ulcers in the foot support area and another that required amputation due to severe infection. Conclusion: Conservative treatment with total contact casting efficiently produced plantigrade, shoeable or braceable feet without pressure ulcers in approximately two-thirds of our small series of patients with diabetic foot insensitivity who suffered calcaneal fracture.
PO 18252 - Advanced surgical salvage therapy for infected diabetic feet
Authors: Diniz Freitas Claudia , Katayama Martha Lúcia , Pires Eduardo Araújo , Roncatto Carlos Eduardo , Attílio Lima Santin Roberto
Published: November 2019

Introduction: Foot infections are common among diabetic patients with peripheral neuropathy and/or peripheral arterial disease and may be the main factor that leads to major or minor lower-extremity amputation. Most deep infections in diabetic feet are preceded by an unnoticed lesion with local penetration of pathogens into deeper tissues. Knowledge of critical issues for diabetic foot management, such as ischemia, wound-healing principles, immunology and microbiology, has changed the traditional approach to the diabetic foot and has led to new advances. The application of tissue engineering, biomedicine and biotechnology with corrective and instrumental surgical techniques for the management of this disease has become an emerging field with demonstrable advantages. This study provides an updated overview of the orthopedic management for extremity salvage of the diabetic foot with deep infection. Methods: Nine patients (10 feet), 7 men and 2 women, whose mean age at hospital admission was 53 years (ranging from 34 to 72), were evaluated retrospectively after salvage therapy of the extremities. We considered the functional clinical outcome good when the patient was able to wear shoes for insensitive feet, acceptable when the patient had residual deformity requiring custom-made orthosis and poor when the patient required extremity amputation. Results: After a mean follow-up of 6 months (ranging from 4 to 14), an average of 7 surgical procedures were performed (ranging from 2 to 23), including angioplasty in 5 patients and amputation at the level of the Lisfranc joint in one patient. Outcomes were good in 9 feet and acceptable in one foot with braceable residual deformity. Conclusion: We believe that an aggressive approach and the use of new technology has numerous attributes that can help to salvage the extremities of seriously ill patients.
PO 18254 - Synovial giant cell tumor of the ankle
Authors: Diniz Freitas Claudia , Araújo Pires Eduardo , Roncatto Carlos Eduardo , Attílio Lima Santin Roberto
Published: November 2019

Introduction: Synovial giant cell tumor is a benign neoplasm that is rarely reported in the form of malignant metastasis. Synovial giant cell tumor most frequently occurs in the hand, hip and knee and rarely occurs in the ankle and foot. The present study describes 2 rare cases of synovial giant cell tumor located in the hindfoot (one with diffuse disease with tibiotarsal and subtalar joint involvement and the other with signs of periarticular ankle involvement) and describes the chosen treatment. Methods: Two consecutive patients were evaluated, and a brief literature review was performed. Results: Open synovectomy was performed in both cases, with complete tumor resection and satisfactory patient progression. Conclusion: Open synovectomy was found to be a good method for the treatment of these lesions because it enabled a satisfactory approach, with good visualization of the ankle compartments and underlying joints and the ability to efficiently provide marginal excision, total synovectomy and complete tumor resection for arthrotomy, without postoperative complications.
TL 18097 - Role of bone graft and bone graft substitutes in isolated subtalar joint arthrodesis
Authors: Godoy-Santos Alexandre Leme , Araoye Ibukunoluwa , Elattar Osama , Naranje Sameer , Netto Cesar de Cesar , Shah Ashish
Published: November 2019

Introduction: Subtalar joint (STJ) arthrodesis is a well-established operative procedure in the treatment of subtalar arthritis and hindfoot deformities. Nonunion remains an important complication, with an incidence and role of risk factors varying in the literature. Recent reports have highlighted a decrease in overall union rates between 96% and 100% to 84%, further strengthening the need for an understanding of risk factors that may be implicated in nonunion rates. Some possible factors have been identified, including smoking, revision surgery, the presence and extent of devascularized bone, and previous ankle joint fusion. Current practice suggests that using bone grafts or bone graft substitutes decreases the risk of its occurrence. Objective: To compare union rates of isolated subtalar arthrodesis with and without the use of bone grafts or bone graft substitutes. Methods: We retrospectively reviewed 135 subtalar fusions with a mean follow-up of 18 ± 14 months. The standard approach was used for all operations. Graft materials included β-tricalcium phosphate, demineralized bone matrix, iliac crest autograft and allograft and allograft cancellous chips. Successful subtalar fusion was determined clinically and radiographically. Results: There was an 88% (37/42) union rate without graft and an 83% (78/93) union rate with bone graft use. The odds ratio of union for graft versus no graft was 0.703 (95% CI, 0.237-2.08). The average time to union in the graft group was 3 ± 0.73 months and 3 ± 0.86 in the nongraft group, with no statistically significant difference detected (p = 0.56). Conclusion: Graft use did not improve union rates for subtalar arthrodesis.
TL 18098 - Radiographic evaluation of the ankle joint after triple arthrodesis
Authors: De Carvalho Marques Bruno , Moreira de Castro Junior Isnar
Published: November 2019

Introduction: Triple foot arthrodesis is a widespread procedure that was first described by Hoke in 1921 and has been perfected over the years. Postsurgical degenerative changes in adjacent joints are highly prevalent (44-58%) according to the literature, and the prevalence of severe cases is 9-27%. This study radiographically assesses the tibiotarsal joint of patients who underwent ipsilateral triple arthrodesis and describes the time of progression of their condition. Methods: In this study, 150 triple arthrodesis procedures were performed from 2010 to 2015. In total, 56 patients (62 operated feet) participated in the study. The ankles were radiographically assessed at the following timepoints: at baseline or during the preoperative period, at 1 year postoperation, and at 3 to 5 years of follow-up. Arthrosis was detected using the Kellgren and Lawrence scale, and the time to secondary arthrosis was measured. Results: At baseline, 31 ankles (50%) showed no clear signs of arthrosis. Tibiotarsal arthrosis worsened by 1 grade in the first postsurgical year in 13 ankles (28.3%). After 3 to 5 years of postoperative follow-up, 21 ankles (55.2%) worsened by 1 grade; arthrosis worsened by 2 or more grades in 15.8% (n=6) of the ankles, and 11 ankles (29%) showed no worsening or onset of tibiotarsal arthrosis. No worsening or onset of tibiotarsal arthrosis was identified for an average of 22 months after the procedure. The mean time of postsurgical progression was 32.4 months among patients whose arthrosis worsened by 1 grade and 43.7 months among those whose arthrosis worsened by 2 or more grades. Conclusion: Radiographic changes strengthened the concept of arthrosis formation secondary to triple arthrodesis of the tibiotarsal joint, even in the short and medium terms. The rates of osteoarthrosis worsened from 49.2% (30 feet) to 70% after 1 year and to 92.3% after 3 to 5 years postoperatively.
TL 18099 - Short-term changes after corticosteroid injections into the normal tendons of rabbits
Authors: Godoy-Santos Alexandre Leme , Innocenti Dinhane Kandir Genesio , Todorovic Fabro Alexandre , Moretto Maria Regina , Depra Igor , Bonetti Yoshida Winston
Published: November 2019

Introduction: Corticosteroid injections in or around tendons for the treatment of athletic injuries are a common practice among orthopedic surgeons and are apparently efficacious in the short term, although controversies persist related to local complications. Objective: This study evaluated short-term (48 hours) biomechanical, biochemical, and histological alterations after a single injection of betamethasone into the normal tendons of rabbits. Methods: A total of 72 New Zealand White rabbits were randomly divided into 2 groups: the test group - in which 36 animals underwent 1 intratendinous injection of betamethasone (1.4 mg / 0.2 mL) in the right calcaneal tendon; the control group - in which the right calcaneal tendon of 36 animals was injected with saline (placebo control group) and the left calcaneal tendon was left untreated for normal standards (normal control). Forty-eight hours later, the animals were euthanized and the tendons harvested. Metalloproteinase (MMP1 and MMP2) and interleukin (IL1 and IL6) expression levels, biomechanical resistance (load 3 elongation parameters), and histomorphometry (hematoxylin and eosin and picrosirius red stains for collagen fibers, tenocytes, and inflammatory cells) were analyzed in the tendons. Results: The test group showed a significant reduction in MMP2 expression compared with the control groups (P = .027). Regarding the other parameters, there were no additional significant differences between the groups. Conclusion: A single injection of corticosteroid into normal calcaneal tendons did not trigger acute local morphological, structural, or biomechanical injuries at 48 hours, but it did promote a significant decrease in MMP2 levels. Additional studies are needed with increased follow-up durations, various doses, and multiple injections and in tendinopathic models.
TL 18104 - Ankle fusion percutaneous home run screw fixation
Authors: Leme Godoy-Santos Alexandre , Phillips Sierra , Roberts Lauren , Naranje Sameer , Shah Ashish , De Cesar Netto Cesar
Published: November 2019

Introduction: During internal fixation of ankle fusions, in addition to the standard crossed screw fixation pattern, the use of a percutaneously placed augmenting screw, directed from the posterolateral tibial metaphysis proximally across the ankle into the talar neck (“home run screw”), is a widely used technique. The placement of this screw is technically demanding, and for the majority of surgeons, multiple attempts under fluoroscopy guidance are frequently needed to achieve perfect positioning of the implant. There is a risk of injury to local neurovascular and tendinous structures. Objective: To identify the number of attempts necessary for perfect positioning of the ankle fusion home run screw and the neurovascular and tendinous structures at risk. Methods: Eleven fresh-frozen cadaver limbs were used. Guide wires for cannulated screw placement were percutaneously placed into the distal posterolateral aspect of the leg under fluoroscopic guidance, with the ankle held in the neutral position. Malpositioned guidewires were not removed and served as guidance for the following pins. The number of guide wires needed to achieve acceptable positioning of the implant was noted. After a layered dissection from the skin to the tibia, we evaluated neurovascular and tendinous injuries and measured the shortest distance between the closest guidewire and the soft tissue structures using a precision digital caliper.  Results: The mean number of guide wires needed to achieve an acceptable positioning of the implant was 2.34 (SD 0.81, range 2 – 4). The mean distances between the closest guide pin and soft tissue structures of interest were as follows: Achilles tendon 5.35 mm (SD 2.74 mm); peroneal tendons 9.65 mm (SD 5.19 mm); posteromedial neurovascular bundle 12.78 mm (SD 7.14 mm). The sural bundle was in contact with the guide pin in 5/11 specimens (45.5%) and impaled in 3/11 specimens (27.3%). In the remaining 3 specimens, the average distance from the sural nerve bundle was 3.58 mm (SD 2.16 mm). Conclusion: The placement of percutaneous ankle fusion home run screws is technically demanding, requiring multiple attempts to achieve acceptable placement. We have shown that important tendinous and neurovascular structures are in close proximity to the guidewires and that the sural bundle is injured in approximately 73% of cases.
TL 18111 - Rate of unsatisfactory syndesmotic reduction according to a postoperative tomographic study
Authors: Christovan Ribeiro Evandro Junior , Damião Prata Sérgio , Rizzo Marco Antônio
Published: November 2019

Objective: To analyze the rate of unsatisfactory reduction of syndesmosis injuries through a postoperative tomographic study. Methods: This is a prospective study conducted from March to December 2017. In total, 30 patients with syndesmosis injury were selected, and ankle tomography was performed during the first postoperative period. A form developed for the study was used to collect demographic data (sex and age in years) and postoperative data (operated side, Weber classification, computed tomography results and need for surgical reoperation). The images were evaluated using tomographic criteria. The intraoperative analysis was based on the results of radioscopy and direct visualization of syndesmosis. Results: Most of the patients were male (56.7%), and their ages ranged from 17 to 51 years. A total of 53.3% of the patients underwent treatment of the left side, 66.7% of patients were classified as type C, and 66.7% of patients did not undergo reoperation. The rate of unsatisfactory syndesmosis reduction was 25.9% based on analyses of the established variables. Although 74.1% of the criteria presented satisfactory outcomes, criterion B had a significant rate (37%) of unsatisfactory outcomes. Conclusion: Tomographic analysis showed a high percentage of unsatisfactory reductions of syndesmosis injuries. Accordingly, despite the use of correct fixation techniques and adequate intraoperative scopic monitoring, postoperative tomography identified cases of distal tibiofibular joint incongruence.
TL 18134 - Treatment of avulsion fractures of the base of the fifth metatarsal with hard-soled shoes and a walking boot
Authors: Cândido Nishikawa Danilo Ryuko , Aires Duarte Fernando , Honda Saito Guilherme , Monteiro Augusto César , Rodrigues de Miranda Bruno , Pires Prado Marcelo
Published: November 2019

Introduction: Conservative treatments for avulsion fractures of the base of the fifth metatarsal described are elasticated bandaging, cast, a walking boot (WB) and hard-soled shoes (HSS). The aim of this study is to compare the clinical and functional outcomes, time to return to previous activities, and time and rate of bone healing of patients with avulsion fracture of the base of the fifth metatarsal treated in an HSS or in a WB. Our hypothesis is that a less rigid immobilization yields the same results. Methods: A comparative cohort study was conducted of 72 patients with acute avulsion fractures of the base of the fifth metatarsal treated with WB or HSS, from March 2014 to November 2018. The mean age of the patients was 41,25 years. There were 56 females and 16 males. Thirty-nine patients were treated with WB and 33 with HSS. Patients with comorbidities that could interfere with bone healing (diabetes, inflammatory joint disease), associated ankle ligament lesions and loss to follow-up were excluded. Patients were followed regularly until they were asymptomatic and able to return to their previous activities (work, daily activities, sports). We retrospectively reviewed medical records containing the visual analogue scale (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) score, as well as radiographic exams to evaluate the time and rate of bone healing. Results: Both groups had similar VAS and AOFAS scores at 8 (p=0,34 and p=0,83) and 12 (p=0,25 and p=0,79) weeks. Age and gender distributions in the two groups were equal (p=0,23 and p=0,34, respectively). Time taken to return to previous activities was not significant different, with the HSS group taking 8,33 weeks and the WB taking 9,73 weeks (p=0,10). The mean time for bone healing was significant longer in the HSS group, lasting 8,64 weeks compared with 7,18 weeks in the WB group (p<0,001). One case of non-union was observed in the WB group and none in the HSS group. Conclusion: Avulsion fractures of the base of the fifth metatarsal can be treated equally with HSS or WB. Both treatments were found to be equivalent in terms of clinical and functional evaluations and return to previous activities.
TL 18141 - Isolated gastrocnemius tightness
Authors: Cristina Stéfani Kelly , De Matos Moraes Leonardo Vinicius , Quadros Borges Vinícius , Ferraz Ferreira Gabriel
Published: November 2019

Introduction: The objective of this study was to evaluate the difference in muscle strength between flexion and ankle extension to test the hypothesis that this predisposes to a dynamic equine and, thus, to evaluate this correlation with pain in the forefoot (metatarsalgias) and hindfoot (plantar fasciitis, tendinopathy of the tendon insertional and non-insertional calcaneus). Methods: In this prospective cohort study, 50 patients were consecutively diagnosed with forefoot pain (metatarsalgias) or pain in the hindfoot (plantar fasciitis, tendonopathy of the insertional and non-insertional calcaneal tendon), and 50 patients had no foot diseases. The body mass index (BMI) was evaluated, and IGT was evaluated through the Silfverskiöld test. The parameter of gastrocnemius contracture was considered in cases of limitation of ankle extension <10. The intervention was to measure flexion strength and ankle extension with a manual dynamometer, evaluating isometric contraction based on the method suggested by Kahn et al. Results: One hundred patients participated in the study, with 50 patients in the study group and 50 in the control group. The mean age was 63.42 years, and the mean BMI was 28.53 in the study group and 62.26 and 28.84 in the control group, with no difference in distribution between age groups (p = 0.634) and for BMI (p = 0.709). The difference was significant between the groups in relation to the Silfverskiöld test (p = 0.019), the ankle force variation in dynamometry (p <0.001) and normalized variation (p <0.001). In addition, a significant difference between groups was observed in the dynamometry of plantar flexion (p <0.001). Conclusion: The hypothesis of causes for sural triceps shortening considered as idiopathic are as follows. The difference in strength between the dorsiflexion musculature and the one that performs the plantar flexion, the delay in neuromuscular activation of the dorsiflexors, or even a combination of these two factors. We demonstrated the possibility of the evaluation of the force through a manual dynamometer that can be used in routine outpatient visits, which proved to be effective and reproducible.
TL - 18148 - Partial plantar fasciotomy for the treatment of plantar fibromatosis
Authors: Mansur Nacime Salomão Barbachan , Azevedo Rafael Mohriak de , Fonseca Lucas Furtado , Silveira Juliana Doering Xavier da , Raduan Fernando Cepolina , Nery Caio Augusto Souza
Published: November 2019

Introduction: Ledderhose's disease (plantar fibromatosis) is an uncommon condition that usually affecting men older than 40 years of age and causes major discomfort and disability. The low response to conservative treatment and the progression of surgical techniques have motivated some professionals to resume considering surgical resolution for this disease. Our study describes the outcomes of a series of cases treated with resection of the affected band. Methods: This is a retrospective study with 14 patients (17 feet) diagnosed with plantar fibromatosis of the medial fascia that was refractory to conservative treatment and was treated surgically from December 2016 to November 2018. All patients were evaluated for improvement in symptoms, for major and minor complications and for relapse during the study period. Results: Our sample consisted of 9 men and 5 women with a mean age of 40.6 years (15-63 years). All patients showed medial fibromatosis and underwent subtotal fasciotomy of the medial fascial band with margins of at least 2 cm. Of the 17 feet, 5 showed relapse (29%) and only 2 required reintervention. Three patients (17%) developed surgical wound dehiscence, although all patients progressed to surgical wound closure with no need for surgical intervention. Two feet showed signs of medial plantar nerve injury, although the branch of the nerve was wrapped in fibromatosis and was also resected in those cases.  Conclusion: Partial plantar fasciotomy is an alternative for the treatment of Ledderhose's disease. Our series showed outcomes in line with those reported in the literature in terms of relapse and postoperative complications. The moderate relapse and reoperation rates should be considered when this procedure is indicated.
TL 18172 - Evaluation of surgical outcomes of arthroscopic subtalar arthrodesis performed through two lateral portals
Authors: De Andrade Gomes Rogério , Vieira da Fonseca Wagner , Humberto Gomes Anderson , Brandão Magalhães João Murilo , Freitas Villela Rafael , Cardoso Pinto Coelho Bernardo
Published: November 2019

Objective: The purpose of this study is to present the surgical outcomes of 12 patients who underwent arthroscopic subtalar arthrodesis using 2 lateral portals (anterior and medial) in the sinus tarsi. Methods: A retrospective study was conducted with 12 patients (7 men and 5 women) with a mean age of 55.1(36-74) years who underwent arthroscopic subtalar arthrodesis through the sinus tarsi from May 2015 to December 2016. The postsurgical follow-up period was 12 months. Union time and postoperative complications were evaluated, and a validated functional questionnaire from the American Orthopedic Foot and Ankle Society (AOFAS) and the pain visual analog scale (VAS) were applied before and after surgery. Results: The mean time to bone fusion was 11.5 weeks. Bone union occurred in all subjects. Four patients developed late complications, 3 of which were related to screw positioning in the calcaneus and one of which was related to residual hindfoot varus deformity. Screw-related complications are common among subtalar arthrodesis techniques, and such complications are considered minor when the effectiveness of the technique is considered. The mean preoperative AOFAS score was 42.3 (27-66) points, whereas the mean postoperative score was 83 (73-94) points. The mean preoperative pain VAS score was 8.1 (5-10) points, and the mean postoperative pain VAS score was 2.1 (0-5) points. The above data are similar to those reported in the main published studies and reflect high bone union rates. Conclusion: Arthroscopic subtalar arthrodesis through 2 lateral portals in the sinus tarsi is a safe and effective technique for the treatment of primary and secondary disorders of the subtalar joint. Surgeons must carefully position the screws and align the hindfoot to avoid complications related to orthopedic hardware and hindfoot varus deformity.
TL 18176 - Platelet-rich plasma versus corticosteroid injection in pain and disability outcomes in patients with plantar fasciitis
Authors: De Souza Guimarães Janice , Arcanjo de Jesus Fabio Luciano , De Oliveira Lomelino So Gustavo Leporace , Fossati Metsavaht Leonardo , Mota Garcia Moreno Marcus Vinicius , Gomes Neto Mansueto
Published: November 2019

Introduction: Fascite Plantar é a causa mais comum de dor no calcanhar e muitas vezes responde a uma ampla gama de terapias. Atualmente existem muitas opções de tratamento, sendo que algumas, como plasma rico em plaquetas e injeção de corticosteroides, apresentam grande sucesso no alívio da dor. Entretanto, não há consenso sobre o melhor método de tratamento. O objetivo desta revisão sistemática e meta-análise foi investigar os efeitos do plasma rico em plaquetas versus injeção de corticosteróides em desfechos de dor e incapacidade no paciente com fascite plantar.  Métodos: Os estudos foram amplamente pesquisados ​​em PubmedMEDLINE, na base de dados PEDro, na biblioteca eletrônica científica online (SciELO) e no registro central de ensaios controlados da Cochrane, desde a data mais antiga disponível até janeiro de 2019. Foram incluídos ensaios clínicos controlados randomizados que compararam os efeitos do plasma rico em plaquetas versus injeção de corticosteróides para paciente com fascite plantar. Foram calculados as diferenças médias (DM) e intervalos de confiança (ICs) de 95%, e a heterogeneidade foi avaliada usando o teste I2. Os cálculos foram feitos usando um modelo de efeito aleatório.  Resultados: Dez artigos preencheram os critérios do estudo, incluindo 475 pacientes com fascite plantar. Os principais resultados incluíram alterações da linha de base no Escore da Escala Visual Analógica (dor) e no Escore da Sociedade Ortopédica Americana do Pé e Tornozelo (incapacidade). A terapia com plasma rico em plaquetas resultou em melhora na dor (DM -1,01 IC95%: -1,8 a -0,3, N=375) em comparação com a injeção de corticosteróides. Não foi encontrada nenhuma diferença significativa na incapacidade (DM 6,5 IC95%: -15,8 a 29,0, N=156) em participantes do grupo de terapia com plasma rico em plaquetas em comparação com o grupo de injeção de corticosteróides. Além disso, nenhum evento adverso grave foi relatado.  Conclusão: O plasma rico em plaquetas foi mais eficaz do que a injeção de corticosteróides e tem o potencial de reduzir a dor do paciente com fascite plantar.