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Objective: To evaluate the efficacy of surgical treatment to correct the main deformities associated with flexible cavovarus foot due to Charcot-Marie-Tooth disease. Methods: Fifteen patients (18 feet) with flexible cavovarus feet due to Charcot-Marie-Tooth disease were evaluated and underwent surgery between 2000 and 2015. We used a “triple surgery” protocol: a combination of plantar fasciotomy, valgus-inducing osteotomy of the calcaneus, and lengthening osteotomy of the first metatarsal. After a mean follow-up time of 105 (48 to 198) months, we developed a numerical scale to assess the main aspects of patient complaints: pain (3 points), function (3 points) and deformity (4 points). The scale considered the results of the visual analog pain scale, the American Orthopedic Foot and Ankle Society Scale, and the Coleman block test, as well as clinical and radiographic evaluation of gait and cavovarus deformities. Results: According to the numerical scale, the results were considered satisfactory in 15 of the 18 feet (84%) and unsatisfactory in 3 (16%). Conclusion: In the medium term, the “triple surgery” protocol proved efficient for correcting cavovarus deformities, providing functional improvement while preserving mobility without pain complaints. In the final analysis, through the “triple surgery” protocol, early indication for arthrodesis can be avoided, postponing sacrifice of the hindfoot joints. Level of Evidence IV; Therapeutic Studies; Case Series.

ResumoAs úlceras e infecções são complicações comuns nos pés dos pacientes diabéticos que já se encontram na fase tardia desta doença sistêmica que se tornou uma verdadeira epidemia do mundo moderno. Neste grupo específico de pacientes, são as infecções que constituem o principal fator envolvido na sequência de eventos que resultam na amputação do membro inferior. A neuropatia periférica (NC) constitui fator determinante na perda da sensibilidade protetora dos pés na fase tardia da doença e, por sua vez, favorece o desenvolvimento das úlceras plantares de pressão (UPP) e a destruição osteoarticular causado pela neuroartropatia de Charcot (NC). A obesidade, a doença arterial periférica (DAP) e a deficiência no sistema imunológico devida aos distúrbios metabólicos do diabetes desempenham papel adicional importante na morbidade desta doença, principalmente no que se refere à amputação dos membros inferiores. É importante para o médico ortopedista compreender que para tentar evitar estas complicações que costumam resultar na amputação da extremidade é necessário estabelecer estratégias de prevenção direcionadas, principalmente, para a educação do paciente diabético e também para medidas protetoras profiláticas.

Objective: 1) to identify characteristics of the functioning and production of training centers responsible for the training of foot and ankle specialists in Brazil; 2) establish minimum quality criteria to provide adequate professional training of the foot and ankle specialist; 3) create a baseline to endorse the minimum foot and ankle specialist training program; 4) to rank, in terms of qualification and efficiency, the training centers of specialists in the area of ​​foot and ankle. Methods: protocol containing information provided by physicians responsible for 31 accredited national services as centers for training foot and ankle specialists at ABTPé in the 2012-2015 quadrennium. Results: minimum operating and production criteria were established based on the information collected. We identified that: 1) it was possible to establish criteria for a possible standardization in the training programs, both in the theoretical and practical field; 2) the relevant scientific output of the training centers is still low and should be stimulated to increase both quantity and quality; 3) the academic qualification of physicians responsible for training specialists is low; 4) The classification of training centers according to hierarchical quality criteria can be established by objective criteria. Conclusion: Quality goals, with objective and well-defined criteria, could be established allowing standardizing the type of training offered to training specialists distributed throughout the national territory, making it more uniform. The evaluation criteria adopted also allowed to establish a hierarchical classification of training centers in the area of ​​foot and ankle, creating a reference base to qualify the training offered in these institutions.

To establish parameters and propose a radiographic classification for foot adduction/supination deformities to assist the indication of Garceau procedure. Secondly, to investigate whether the outcome of Garceau surgery depends on the initial treatment used, peritalar release, or the Ponseti method, and verify the maintenance of correction until skeletal maturity.Prospective cohort study, with follow-up evaluations in 2009 and 2019. Fifty-three consecutive patients (71 feet) with idiopathic congenital clubfoot (ICCF) were divided into two groups according to the initial treatment used: peritalar release (group I) or Ponseti method (group II). All patients underwent Garceau procedure. The patients were evaluated clinically and radiographically using the American Orthopedic Foot Association (AOFAS) score for ankle and hindfoot. A radiographic classification is proposed based on the adduction by talo-first metatarsal angle on dorsoplantar view and supination by the elevation of the head of the first metatarsal on lateral view, both weight-bearing.In the first clinical evaluation, the mean score on the AOFAS was 87 points in group I and 86 points in group II. In the second evaluation, group I had mean AOFAS of 92 points and group II of 94 points. No statistical differences were found between the two groups, neither between the first and the second evaluation. In the radiographic evaluation, the adduction deformity obtained an average correction of 4° in group I and 3.6° in group II; in supination deformity, the average depression of the first metatarsal head in relation to the ground was 6.7 mm in group I and 7.5 mm in group II, with no statistical difference between the two evaluations, indicating the correction was maintained until skeletal maturity.Garceau transfer is capable of correcting residual deformities in adduction/supination of mild and moderate degrees, regardless of the initial treatment, and maintaining the correction until skeletal maturity. The proposed radiographic classification might help to objectively indicate the surgical procedure.

Resumo Objetivo Avaliar a capacidade da artrodese tríplice de aliviar as principais queixas dos pacientes que apresentam pé plano adquirido do adulto (PPAA): 1) dor incapacitante localizada no médio e retropé; 2) deformidades marcadas pelo colapso do arco medial, valgo, abdução e supinação. Método Avaliamos 17 pacientes (20 pés) portadores de PPAA em estado avançado que foram submetidos à correção cirúrgica pela artrodese tríplice modelante. A média de idade dos pacientes no momento da cirurgia foi de 62 anos (variação de 38 a 79 anos), e o tempo médio de seguimento foi de 43 meses (variação de 18 a 84 meses). Utilizamos critérios clínicos empregando a escala visual analógica da dor (EVAD) e a escala funcional da American Orthopaedic Foot and Ankle Society (AOFAS, na sigla em inglês) do retropé para avaliar a eficácia da cirurgia. Resultados A dor residual mensurada pela EVAD foi de três pontos, em média. Observamos incremento médio de 23% nos valores da escala AOFAS do retropé após o tratamento cirúrgico. A correção das deformidades foi satisfatória em 10 de 20 pés; parcialmente satisfatória em 4 de 20 pés; parcialmente insatisfatória em 5 de 20 pés; e insatisfatória em 1 de 20 pés. Conclusão Apesar da artrodese tríplice modelante indicada no tratamento do PPAA em estágio avançado apresentar alto índice de consolidação óssea, a correção incompleta das deformidades pré-existentes e a persistência de dor residual contribuíram para a elevada taxa de decepção dos pacientes com o resultado da cirurgia.

Objective: This study evaluated the effectiveness of Charcot arthropathy (CA) surgery to align and stabilise the severely deformed hindfeet of patients with diabetes so that the affected limb would be able to support patients’ body weights and restore walking independence. Methods: A total of 25 patients with cases of CA compromising the ankle (type IIIA) or hindfoot (type IV) underwent a procedure to salvage their affected limbs via tibiocalcaneal arthrodesis fixed with an interlocking intramedullary nail. The mean follow-up period was 49 (6–169) months, and the mean age of patients was 54 (30–83) years. The outcome was considered as satisfactory in cases where the patients were able to walk independently and maintain their repaired foot on the ground; the outcome was considered as unsatisfactory when the affected limb presented with frank instability or deformity. Results: The outcomes were satisfactory in 19 of the 25 (76%) repaired limbs, although 11 of the 25 (44%) limbs presented with complications. Conclusions: The salvage of a severely deformed and markedly unstable limb due to CA complications involving the ankle (type IIIA) or hindfoot (type IV) should be considered for patients with diabetes because the prognosis is favourable in cases where the affected limb is surgically treated using tibiocalcaneal arthrodesis and an interlocking intramedullary nail. Level of Evidence IV; Therapeutic Studies; Case Series.

Objective: To evaluate the prognosis of specialized orthopedic treatment to obtain a functional foot and ankle in diabetic patients with neglected Charcot arthropathy (NCA). Methods: Sixty-five patients with NCA were treated in the period between 2000 and 2017, according to a systematized protocol adopted atour institution. Six patients (9%) were lost to follow-up, and the remaining 59 patients had a total of 63 affected extremities (four patients were bilaterally affected). The mean follow-up time was 72 months (range 12 to 132 months), and the mean age was 54 years (range 30 to 80 years). We considered the results satisfactory when the patient was able to walk independently, fully supporting the foot on the ground. We considered the results unsatisfactory when the affected extremity presented a frank instability and was deformed to the point that it was not possible to accommodate it in a stabilizing orthesis or support it during gait or when amputation was necessary. Results: We obtained an unsatisfactory result in 31 of the 59 patients (53%). Only 31 of the 63 extremities (49%) were considered functional after treatment. Conclusion: The prognosis of NCA treatment using the systematized treatment protocol is poor. Only half of the treated extremities were capable of plantar support and independent gait. Level of Evidence IV; Prognostic Studies; Case Series.

Objective: The objective of this study was to evaluate the efficacy of the systematic protocol developed in our institution for the treatment of Charcot arthropathy (CA) of the midfoot, specifically for cases anatomically classified as Brodsky type II. Methods: Sixty patients with type II CA were treated in the period between 1997 and 2017 following a systematic protocol adopted at our institution. Two patients (3%) were lost to follow-up, leaving a total of 58 patients with 64 feet (six had bilateral involvement). The mean follow-up time was 31 months (range 12 to 150), and the mean age was 55 years (range 27 to 73). Conservative treatment was indicated in 41/64 of the extremities (64%), and surgical treatment was indicated in 23/64 of the extremities (36%). We considered the result as satisfactory when the patient was able to walk independently, placing full body weight on the foot. The result was considered unsatisfactory when the affected extremity presented clear instability and was deformed to the point that it was not possible to fit it in a stabilizing orthosis or for the patient to place their weight on the foot during walking as well as when it was necessary to perform an amputation. Results: We obtained a satisfactory outcome in 54/60 patients (90%) and in 58/64 feet (91%). In 19/23 of the operated feet (83%) and 39/41 of the conservatively treated feet (95%), the result was atisfactory. Conclusion: The systematic treatment protocol developed at our institution allows achievement of a favorable prognosis regarding the clinicalfunctional outcome of type II CA, with conservative treatment being sufficient in most cases. Level of Evidence IV; Prognostic Study; Retrospective study.

Introduction: Amniotic band constriction syndrome is a rare anomaly with an incidence of approximately 1:15,000 live births. It manifests as fibrous amniotic bands involving the deep fascia and, depending on its depth, can compromise the venous and lymphatic system. The presence of fibrous amniotic bands in the lower limbs is strongly associated with foot malformations, and the prevalence of clubfoot under such conditions ranges from 12 to 56%. Clubfoot associated with amniotic band constriction syndrome is characterized by rigidity and edema and tends to respond poorly to conservative treatment. We present a series of cases of clubfoot associated with amniotic band constriction syndrome that were treated with manipulation and plaster casting using the Ponseti method. Methods: Over the past 10 years, we followed 19 patients with amniotic band constriction syndrome affecting the lower limbs. Of these patients, 6 had clubfoot, including 2 who were bilaterally affected. The 6 children in this series had constriction bands in Hennigan and Kuo zone 2. The 8 affected feet were rigid, with a mean Pirani score of 5.5 and Dimeglio III classification. Four extremities with complete constriction bands initially underwent z-plasty for band release, followed by manipulation and plaster casting. The other four extremities had incomplete bands, which were initially subjected to manipulation using the Ponseti method, followed by band release at the time of the Achilles tenotomy. Results: Over a mean follow-up time of 5 years, 7 of the study feet were plantigrade and painless, with no limitations of activities of daily living; only one foot showed limited dorsiflexion, and that patient is awaiting corrective surgery. This limb showed a double band in zone 2 that was both complete and deep. Conclusion: Despite the rigidity, clubfoot secondary to amniotic band constriction syndrome showed good outcomes when treated using the Ponseti method.

Introduction: Charcot arthropathy can lead to joint destruction and often causes ulcers at sites of bony prominences. In the ankle, it causes instability that limits gait and makes it difficult for patients to wear shoes or orthoses. This was a retrospective study describing cases of Charcot arthropathy of the ankle treated at our institution from 1997 to 2017. Methods: Over the study period, we treated 252 patients with Charcot arthropathy. Of these patients, 27 presented the disease exclusively in the ankle. The selected cases were unilateral; 17 of the patients were men, and the mean age was 55 years. Nine patients were treated conservatively, and 18 were treated surgically to stabilize the ankle (including the hindfoot, if necessary). During surgery, different fixation methods were used depending on the presence or absence of ulcer at the time of the intervention. At the end of the treatment, we assessed the patient’s ability to wear shoes or orthoses for walking, the stability of the ankle joint and, in surgical cases, union. We considered a good outcome when the patient was able to walk wearing shoes or orthoses, and the limb was stable; an acceptable outcome when the limb was unstable, but the patient adapted to orthoses; and a poor outcome when the patient was unable to walk, and the ankle was unstable or amputated. Results: Nine patients underwent conservative treatment using total contact casting at the initial phase of the disease, followed by orthosis after union. Of these patients, the outcome was poor for 5, good for 3 and acceptable for 1. Eighteen patients underwent reconstructive surgery; 12 patients had a good outcome; 2 patients underwent amputation, and 4 patients had unsuccessful surgeries. Conclusion: Charcot arthropathy of the ankle causes considerable instability. Conservative treatment of the disease fails to provide good outcomes, and the patients who underwent reconstructive surgery had the best functional and clinical evaluations.

Introduction: Pes cavus is a deformity characterized by a high longitudinal medial arch. It is classically associated with neurological conditions, among which Charcot-Marie-Tooth (CMT) disease is the most common. Treatment options depend on the flexibility of the deformity. Various procedures are available to correct flexible pes cavus; these procedures can be performed in combination, and there is no standardized technique. There is limited information in the literature on the long-term outcome of treatment, and thus far, there is no consensus on the ideal surgery. The objective of the present study was to assess the efficacy of triple surgery (TS) (plantar fasciotomy, valgising calcaneal osteotomy and first metatarsal extension osteotomy) in the long-term treatment of pes cavus of patients with CMT. Methods: Between 2000 and 2015, 15 patients with CMT and pes cavus who underwent TS were treated at our department, including a total of 18 feet from 8 women and 7 men. The mean age of the patients at the time of the surgery was 21 years (9 to 60 years), and the mean follow-up time was 11 years (4 to 19 years). Of the 18 feet that underwent TS, 14 required an additional procedure. To analyze the outcomes of TS, criteria were stipulated and divided into 3 categories: pain (A), deformity (B) and function (C). The following criteria were analyzed: category A: AOFAS pain subscale, pain visual analog scale; category B: clinical and radiographic pes cavus, clinical and radiographic hindfoot varus; category C: gait, flexibility and AOFAS-function subscale. Each analyzed subitem was scored (total score: 10 points) to determine whether correction was achieved and maintained until the final assessment according to different objective criteria. The outcome was considered good when the score was 8 points or more, fair when the score ranged from 5 to 7 points, and poor when it was 4 points or less. Results: When pre-established criteria were objectively applied, 10 feet had a good outcome, 5 feet had a fair outcome, and 3 feet had a poor outcome; thus, a total of 15 feet (83%) had a satisfactory long-term outcome. Conclusion: Triple surgery was effective for treating patients with CMT, providing good deformity correction of pes cavus in addition to long-term clinical and functional improvement.

Objective The present study aims to evaluate the ability of triple arthrodesis in eliminating the main complaints presented by patients with adult acquired flatfoot deformity (AAFD): 1) disabling hindfoot pain; 2) major deformities, such asmedial arch collapse, valgus, abduction, and supination. Methods A total of 17 patients (20 feet) with advanced AAFD who underwent surgical correction by triple arthrodesis were evaluated after a mean follow-up period of 43 months (range: 18-84 months). The average age of the patients at surgery was 62 years old (range: 38-79 years old). The visual analogue scale (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score were used to assess the final results. Results According to the VAS, the average residual pain was 3 points; the AOFAS hindfoot score points increased 23% after the surgery; and the correction of deformities was considered satisfactory in 10 out of 20 feet; partially satisfactory in 4 out of 20 feet; partially unsatisfactory in 5 out of 20 feet; and unsatisfactory in 1 out of 20 feet. Conclusion Despite the high index of bone fusion after triple arthrodesis, which is the gold standard treatment in advanced AAFD, the incomplete correction of major deformities and the persistence of residual pain contributed to a high disappointment rate of the patients with the surgical results. Resumo Objetivo Avaliar a capacidade da artrodese tríplice de aliviar as principais queixas dos pacientes que apresentam pé plano adquirido do adulto (PPAA): 1) dor incapacitante localizada no médio e retropé; 2) deformidades marcadas pelo colapso do arco medial, valgo, abdução e supinação. Método Avaliamos 17 pacientes (20 pés) portadores de PPAA em estado avançado que foram submetidos à correção cirúrgica pela artrodese tríplice modelante. A média de idade dos pacientes no momento da cirurgia foi de 62 anos (variação de 38 a 79 anos), e o tempo médio de seguimento foi de 43 meses (variação de 18 a 84 meses). Utilizamos critérios clínicos empregando a escala visual analógica da dor (EVAD) e a escala funcional da American Orthopaedic Foot and Ankle Society (AOFAS, na sigla em inglês) do retropé para avaliar a eficácia da cirurgia. Resultados A dor residual mensurada pela EVAD foi de três pontos, em média. Observamos incremento médio de 23% nos valores da escala AOFAS do retropé após o tratamento cirúrgico. A correção das deformidades foi satisfatória em 10 de 20 pés; parcialmente satisfatória em 4 de 20 pés; parcialmente insatisfatória em 5 de 20 pés; e insatisfatória em 1 de 20 pés. Conclusão Apesar da artrodese tríplice modelante indicada no tratamento do PPAA em estágio avançado apresentar alto índice de consolidação óssea, a correção incompleta das deformidades pré-existentes e a persistência de dor residual contribuíram para a elevada taxa de decepção dos pacientes com o resultado da cirurgia.

OBJETIVO: Avaliar o resultado clínico-funcional e radiográfico dos pacientes com fraturas do colo do tálus tratados pelo Grupo de Cirurgia do Pé e Tornozelo da Santa Casa de São Paulo. MÉTODO: Avaliamos 20 pacientes, com tempo médio de seguimento de 71 meses: um com fratura do tipo I, 12 do tipo II, cinco do tipo III e dois do tipo IV, sendo quatro fraturas expostas. RESULTADOS: Um paciente foi tratado incruentamente, 16 com RAFI (três com artrodese subtalar primária), um com talectomia e dois com artrodese tibiotalocalcaneana. A redução obtida foi classificada como anatômica em sete pés, aceitável em seis, e ruim em quatro. Sete pacientes apresentaram complicações precoces. Houve um retardo de consolidação e quatro osteonecroses do corpo do tálus. Quatro pacientes necessitaram de procedimentos reconstrutivos secundários. Sessenta e dois porcento dos pacientes não apresentaram comprometimento radiográfico importante na articulação do tornozelo e 25% na articulação subtalar. Dos pacientes não submetidos a procedimentos secundários, 81% apresentaram queixas referentes ao pé tratado, 37,5% apresentaram alguma deformidade, 44% déficit sensitivo e 50% estavam aposentados. A perda média de movimento do tornozelo foi de 49% e da subtalar 80%. A pontuação média pela escala AOFAS foi de 73 pontos. CONCLUSÃO: A fratura do colo do tálus leva a alta incidência de complicações clínico-funcionais e radiográficas. OBJETIVE: To evaluate the clinical, functional and radiographic outcomes of talar neck fractures in patients treated at the Foot and Ankle Surgery Group of the Santa Casa de São Paulo. METHOD: 20 patients were evaluated. Mean follow-up time was 71 months. One fracture was classified as Hawkins Type I, 12 as Hawkins type II, five as Hawkins type III, two as Hawkins type IV, and four fractures were open. RESULTS: One patient was treated conservatively, 16 were treated with ORIF (three with primary subtalar arthrodesis), one treated with talectomy and two with tibiotalocalcaneal arthrodesis. The reduction was anatomical in seven feet, acceptable in six feet and poor in four. Seven patients had early complications. There was one delay of consolidation and four talar body osteonecrosis. No signs or minimal signs of radiographic arthritis of the affected ankles were found in 62% of the patients and 25% of affected subtalar joints. Of the 16 patients who did not require secondary procedures, 81% complained about the treated foot, 37.5% showed some deformity, 44% had decreased skin sensitivity and 50% never returned to work. The mean loss of motion in the ankle was 49%, and in the subtalar joint, 80%. The average AOFAS score was 73 points. CONCLUSION: Talar neck fractures are associated with high rates of clinical, functional and radiographic complications.

Objective: To assess the result of the treatment of moderate to severe hallux valgus with osteotomy of the first metatarsal base associated to distal release of soft parts and medial capsuloplasty. Methods: 13 patients were assessed (15 feet) submitted to surgical treatment of hallux valgus moderate to severe. The mean follow-up time was 102 months; there were 12 female and 1 male patients, with mean age at the time of surgery of 49 years. The patients enrolled were interviewed according to the questionnaire developed by our service, clinically examined according to the AOFAS scale and submitted to X-ray tests for comparing the results with baseline images. Results: The mean score of the AOFAS scale obtained at the final assessment was 82 points. Nine of the 15 feet (60%) showed some late complications, with four (27%) varus deformities, three (20%) recurrences; two patients (13%) presenting with pain complaints with no associated deformity. In the hallux metatarsophalangeal joint, movement loss was 41° (57%); dorsiflexion movement was mostly affected, with a mean loss of 37° (60%). The range of motion on the contralateral intact side served as control group. Arthrosis progression was seen on the final X-ray evaluation. In all cases, shortening and lifting of the first metatarsal were noticed; however, we couldn't correlate the shortening and lifting with metatarsalgia, plant callosity or lower scoring on the AOFAS scale at the final evaluation. Conclusions: The osteotomy technique by the basis and with distal realignment of soft parts employed in the treatment of moderate to severe hallux valgus showed a high rate of late complications. Due to the high number of complications, we believe that adopting this technique for correcting hallux valgus deformities should be carefully considered.

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.

Objectives: To outline the epidemiological profile of diabetic patients with Charcot arthropathy affecting the midfoot alone or extending from the midfoot to the hindfoot; To assess the results from the treatment that these patients undergo, according to a preestablished protocol, over the medium term. Methods: We retrospectively evaluated 88 patients (110 extremities) with Charcot arthropathy of the midfoot. The minimum follow-up period was 12 months. We included 45 patients with Charcot arthropathy affecting the tarsal-metatarsal joints (51%); 20 patients in whom the talonavicular, calcaneocuboid and subtalar joints were affected (23%); and 23 patients in whom both the midfoot and hindfoot were affected (26%), as described by Brodsky and Trepman. We defined the treatment as successful when a functional foot was preserved; and unsuccessful when the foot was amputated. Results: From treating Charcot arthropathy primarily involving the midfoot were satisfactory in the cases of 75 patients (85%) treated according to our protocol. For the patients with severe lesions affecting both the midfoot and the hindfoot, a greater number of complex operations (i.e. arthrodesis) were needed in order to obtain the same overall rate of satisfactory results. The osteoarticular lesions originating in the midfoot probably extended progressively to the hindfoot because of delayed diagnosis with inadequate early treatment. Conclusion: It was possible to preserve a functional extremity in 85% of the patients. Severe lesions involving the midfoot and extending to the hindfoot required a greater number of surgical procedures to treat them.

Objective: To evaluate the correction of the intermetatarsal angle after arthrodesis of the metatarsophalangeal joint of the hallux. We believe that varus deformity of the first metatarsal can be corrected after arthrodesis of the first metatarsophalangeal joint, without the need for proximal osteotomy. Methods: Forty-three feet of patients who had undergone arthrodesis of the first metatarsophalangeal joint between May 1997 and October 2009 were retrospectively analyzed by means of radiographs. The mean length of follow-up was 58 months. Measurements on the metatarsophalangeal angle, intermetatarsal angle and sesamoid dislocation were made using radiographs made before, immediately after and later on after the operation. Results: The mean metatarsophalangeal angle was 37.6 degrees preoperatively, 12.8 degrees immediately after the operation and 16.4 degrees later on after the operation. The mean intermetatarsal angle was 16 degrees preoperatively, 10 degrees immediately after the operation and 10.2 degrees later on after the operation. Regarding sesamoid dislocation, preoperative radiographs showed most feet to be classified as G3; immediately after the operation, most were classified as G2; and later on after the operation, most were G1. Conclusion: The intermetatarsal angle and sesamoid dislocation improved with arthrodesis of the first metatarsophalangeal joint, without the need for osteotomy at the base of the first metatarsal.

OBJETIVO: Avaliar o resultado clínico-funcional e radiográfico dos pacientes com fraturas do colo do tálus tratados pelo Grupo de Cirurgia do Pé e Tornozelo da Santa Casa de São Paulo. MÉTODO: Avaliamos 20 pacientes, com tempo médio de seguimento de 71 meses: um com fratura do tipo I, 12 do tipo II, cinco do tipo III e dois do tipo IV, sendo quatro fraturas expostas. RESULTADOS: Um paciente foi tratado incruentamente, 16 com RAFI (três com artrodese subtalar primária), um com talectomia e dois com artrodese tibiotalocalcaneana. A redução obtida foi classificada como anatômica em sete pés, aceitável em seis, e ruim em quatro. Sete pacientes apresentaram complicações precoces. Houve um retardo de consolidação e quatro osteonecroses do corpo do tálus. Quatro pacientes necessitaram de procedimentos reconstrutivos secundários. Sessenta e dois porcento dos pacientes não apresentaram comprometimento radiográfico importante na articulação do tornozelo e 25% na articulação subtalar. Dos pacientes não submetidos a procedimentos secundários, 81% apresentaram queixas referentes ao pé tratado, 37,5% apresentaram alguma deformidade, 44% déficit sensitivo e 50% estavam aposentados. A perda média de movimento do tornozelo foi de 49% e da subtalar 80%. A pontuação média pela escala AOFAS foi de 73 pontos. CONCLUSÃO: A fratura do colo do tálus leva a alta incidência de complicações clínico-funcionais e radiográficas.

A simplified standard setting of the circular external fixator allows correction of all the complex deformities of recurrent clubfoot with minimal surgical intervention and no major complications. In those cases where additional corrective arthrodesis is necessary, it is performed with minimal bone resection because the severe deformities of the foot and ankle have already been corrected.

OBJETIVOS: Traçar o perfil epidemiológico dos pacientes diabéticos portadores de artropatia de Charcot acometendo exclusivamente o mediopé ou estendendo-se do mediopé ao retropé. Avaliar, a médio prazo, o resultado do tratamento a que esses pacientes são submetidos seguindo um protocolo preestabelecido. MÉTODOS: Avaliamos, retrospectivamente, 88 pacientes (110 extremidades) portadores de artropatia de Charcot do mediopé, com seguimento mínimo de 12 meses. Incluímos os pacientes portadores de artropatia de Charcot acometendo as articulações tarsometatársicas, 45 pacientes (51%); as articulações talonavicular, calcaneocuboide e subtalar, 20 pacientes (23%); e aqueles com envolvimento do mediopé e retropé, 23 pacientes (26%), segundo Brodsky e Trepman. Definimos como sucesso a preservação de um pé funcional e insucesso como amputação do pé. RESULTADOS: O tratamento da artropatia de Charcot envolvendo primariamente o mediopé foram satisfatórios em 75 pacientes (85%) tratados seguindo nosso protocolo. Nos pacientes com lesões graves, acometendo tanto o mediopé quanto o retropé, foi necessário maior número de cirurgias complexas do tipo artrodese para se obter o mesmo índice global de resultados satisfatórios. A lesão osteoarticular originada no mediopé provavelmente estende-se progressivamente ao retropé devido à demora no diagnóstico no início do tratamento adequado. CONCLUSÃO: Foi possível preservar uma extremidade funcional em 85% dos pacientes. Lesões graves envolvendo o mediopé e estendendo-se ao retropé necessitaram maior número de cirurgias para o tratamento. OBJECTIVES: To outline the epidemiological profile of diabetic patients with Charcot arthropathy affecting the midfoot alone or extending from the midfoot to the hindfoot; To assess the results from the treatment that these patients undergo, according to a preestablished protocol, over the medium term. METHODS: We retrospectively evaluated 88 patients (110 extremities) with Charcot arthropathy of the midfoot. The minimum follow-up period was 12 months. We included 45 patients with Charcot arthropathy affecting the tarsal-metatarsal joints (51%); 20 patients in whom the talonavicular, calcaneocuboid and subtalar joints were affected (23%); and 23 patients in whom both the midfoot and hindfoot were affected (26%), as described by Brodsky and Trepman. We defined the treatment as successful when a functional foot was preserved; and unsuccessful when the foot was amputated. RESULTS: From treating Charcot arthropathy primarily involving the midfoot were satisfactory in the cases of 75 patients (85%) treated according to our protocol. For the patients with severe lesions affecting both the midfoot and the hindfoot, a greater number of complex operations (i.e. arthrodesis) were needed in order to obtain the same overall rate of satisfactory results. The osteoarticular lesions originating in the midfoot probably extended progressively to the hindfoot because of delayed diagnosis with inadequate early treatment. CONCLUSION: It was possible to preserve a functional extremity in 85% of the patients. Severe lesions involving the midfoot and extending to the hindfoot required a greater number of surgical procedures to treat them.

Background: The purpose of our study was to analyze the long-term outcome of salvage surgery in severely injured feet. Material and Methods: Clinical-functional scores and radiographic findings were used to assess the outcome of 18 patients (19 feet) with severe trauma to the foot treated at a tertiary teaching hospital from January, 1985 to October, 2005. Fourteen males and four females with a mean age of 35 years were studied. The mean followup period was 76 months. Results: There was a high incidence of late complications and poor functional results (mean AOFAS = 68/100): chronic pain, 15 of 19 (mean analogical pain score 3.4/10); global foot stiffness, 11 of 19 (with radiographic evidence of arthritis of the remaining foot joints in 13 of 19); residual deformity, 13 of 19; arterial-venous insufficiency, 12 of 19; signs of reflex sympathetic dystrophy, seven of 19; chronic ulcers, six of 19; and chronic osteomyelitis, two of 19. Twelve patients had a visible limp and only 8 of 19 returned to work. Conclusions: Five years after severe foot injury most patients had painful stiffness and only 40% returned to work. Long-term clinical-functional results of the severely injured foot may be disappointing.

OBJETIVO: Identificar o perfil epidemiológico dos pacientes que procuram tratamento ortopédico das complicações nos pés e tornozelos relacionadas ao diabetes, além de correlacionar à sequência de eventos que culminam na amputação da extremidade. MÉTODO: analisamos os dados de prontuário de 300 pacientes no período compreendido entre março de 1997 a julho de 2006. RESULTADOS: A média de idade foi 61 anos, destes, duzentos e setenta e três pacientes (91%) apresentavam diagnóstico de diabetes do tipo II, onde somente 49 (16,3%) faziam controle regular da glicemia. Quatrocentos e cinco extremidades apresentavam problemas afetando a função do pé ou tornozelo, detacando-se: 102 extremidades (34%) com lesões osteoarticulares relacionadas a neuroartropatia de Charcot; 181 extremidades (60,4%) com ulceração crônica e 97 extremidades (32,4%) com infecção. Após tempo médio de seguimento 14 pacientes (4,6%) foram a óbito. CONCLUSÃO: A ulceração na planta dos pés foi a complicação mais frequente na nossa série de pacientes que, estavam na sétima década de vida, apresentavam diabetes do tipo II, faziam uso irregular de insulina e não realizavam controle adequado da glicemia. A perda da sensibilidade protetora nos pés, em associação com deformidade pré-existente, foi identificada como a principal causa das infecções secundárias culminando com a amputação da extremidade. OBJECTIVE: To identify the epidemiological profile of patients undergoing orthopedic treatment for complications of the feet and ankles due to diabetes, and to try to establish the sequence of events that led to amputation of the limb. METHOD: The medical records of 300 diabetic patients treated from March, 1997 to July, 2006 were systematically reviewed. RESULTS: The mean age of the patients was 61 years. Of these, two hundred and seventy three (91%) were diagnosed with type II diabetes, but only 49 (16.3%) had proper medical supervision and control of their glycemia levels. Problems affecting the function of the foot and ankle were found in 405 limbs, with: 102 osteoarticular deformities associated with Charcot's neuroarthropathy (34%); 181 chronic ulcers (60.4%); and 97 infected limbs (32.4%). After the average follow-up time, 14 patients (4.6%) died. CONCLUSION: Ulceration of the sole of the foot was the most common complication in our series of patients, the majority of whom were in their seventies, presented type II diabetes, were insulin dependent, and did not have adequate control of glycemia. Loss of sensitivity of the foot, associated with pre-existing deformities, were identified as the main causes of secondary infections culminating in amputation of the limb.

OBJETIVOS: Avaliar o resultado da correção do hálux valgo moderado ou grave com a osteotomia da base do I metatarsal, associada à liberação distal de partes moles e capsuloplastia medial. MÉTODOS: Foram avaliados 13 pacientes (15 pés), submetidos à cirurgia para correção de hálux valgo moderado ou grave. O tempo médio de seguimento foi de 102 meses, 12 pacientes eram do sexo feminino e um do masculino, com média de idade, no momento da cirurgia, de 49 anos. Os pacientes convocados foram entrevistados segundo questionário desenvolvido no serviço, avaliados clinicamente conforme o escore de AOFAS e submetidos a exames radiográficos para comparação com os pré-operatórios. RESULTADOS: A média da pontuação da escala da AOFAS obtida na avaliação final foi de 82 pontos. Nove dos 15 pés (60%) apresentaram alguma complicação tardia, sendo quatro (27%) deformidades em varo, três (20%) recidivas; dois pacientes (13%) com queixa de dor sem deformidade associada. Na articulação metatarsofalângica do hálux a perda do movimento foi de 41º (57%); o movimento em dorsiflexão foi o mais afetado, com perda de 37º em média (60%). A amplitude de movimento do lado contralateral não operado foi utilizada como grupo controle. Observou-se progressão da artrose na avaliação radiográfica final. Em todos os casos, houve encurtamento e elevação do primeiro metatarsal, porém não foi possível correlacionar o encurtamento e elevação com metatarsalgia, calosidade plantar ou menor pontuação na escala AOFAS na avaliação final. CONCLUSÕES: A técnica de osteotomia da base e realinhamento distal de partes moles, utilizada para correção de hálux valgo moderado a grave, mostrou elevado índice de complicações tardias. Devido ao elevado número dessas complicações, acreditamos que a eleição dessa técnica para correção do hálux valgo deve ser considerada com cautela. OBJECTIVE: To assess the result of the treatment of moderate to severe hallux valgus with osteotomy of the first metatarsal base associated to distal release of soft parts and medial capsuloplasty. METHODS: 13 patients were assessed (15 feet) submitted to surgical treatment of hallux valgus moderate to severe. The mean follow-up time was 102 months; there were 12 female and 1 male patients, with mean age at the time of surgery of 49 years. The patients enrolled were interviewed according to the questionnaire developed by our service, clinically examined according to the AOFAS scale and submitted to X-ray tests for comparing the results with baseline images. RESULTS: The mean score of the AOFAS scale obtained at the final assessment was 82 points. Nine of the 15 feet (60%) showed some late complications, with four (27%) varus deformities, three (20%) recurrences; two patients (13%) presenting with pain complaints with no associated deformity. In the hallux metatarsophalangeal joint, movement loss was 41º (57%); dorsiflexion movement was mostly affected, with a mean loss of 37º (60%). The range of motion on the contralateral intact side served as control group. Arthrosis progression was seen on the final X-ray evaluation. In all cases, shortening and lifting of the first metatarsal were noticed; however, we couldn't correlate the shortening and lifting with metatarsalgia, plant callosity or lower scoring on the AOFAS scale at the final evaluation. CONCLUSIONS: The osteotomy technique by the basis and with distal realignment of soft parts employed in the treatment of moderate to severe hallux valgus showed a high rate of late complications. Due to the high number of complications, we believe that adopting this technique for correcting hallux valgus deformities should be carefully considered.

Background: Severe recurrent clubfoot deformities are challenging to treat. The Ilizarov method offers a safer alternative; however, the management of the device is complex. Methods: A simplified standard setting of the Ilizarov device was used to treat 29 patients (35 feet) with a mean age of 14 years with severely stiff recurrent clubfoot deformities and large scars caused by one or more previous surgeries. This simplification involved a correction in two stages: first a gradual correction of the equinus, varus, cavus, and adduction deformities and later an acute correction of the supination deformity. All feet underwent percutaneous Achilles tenotomy and plantar fasciotomy; 11 feet required an additional midfoot osteotomy. The final outcome was scored as good (complete correction and no pain); fair (partial correction with plantigrade foot and occasional pain); or poor (nonplantigrade foot and continuous pain during walking). Results: After a mean followup of 56 months, the results were good in 27 feet (77%), fair in five feet (14%), and poor in three feet (9%). Early complications were complete dislocation of the first metatarsophalangeal joint in two feet and partial dislocation of the distal tibial epiphysis in two feet. Late complications were recurrence of the deformity (11 feet), spontaneous ankylosis (16 feet), and symptomatic foot and ankle arthritis (7 feet). Arthrodesis was performed in 13 feet at an average of 21 months after the index surgery to treat symptomatic arthritis or correct disabling residual deformities. Conclusions: The Ilizarov device allowed correction of all the complex deformities of severe recurrent clubfoot with minimal operative intervention. Complications were numerous but manageable and for the most part did not compromise overall patient satisfaction in this very difficult to treat clinical condition.

Background: This study was conducted to evaluate the corrective capability of the Ilizarov external fixator in the treatment of neglected clubfoot. Methods: Thirty patients (38 feet) with a mean age of 19 (5 to 39) years with severe deformities and stiff feet associated with neglected clubfoot were studied. A limited soft-tissue dissection, Achilles tenotomy, and plantar fasciotomy were done. Progressive correction of the deformities was achieved through a standard setting of the Ilizarov external fixator. The device was used for 16 weeks, on average, and after removal a short-leg walking cast was used for an additional 6 weeks, followed by an ankle-foot orthosis (AFO) for 6 months. Results: The final outcome was scored as good (complete correction and no pain); fair (partial correction with plantigrade foot and occasional pain); or poor (nonplantigrade foot and continuous pain during walking). After a mean followup of 58 (range 12 to 107) months, the results were good in 30 feet (78.9%); fair in three feet (7.9%); and poor in five feet (13.2%). Early complications were a distal tibial fracture in one foot, dislocation of the first metatarsophalangeal joint in one foot, and arterial damage that resulted in amputation of the toes in one foot. Recurrence of the deformity was found in 19 feet (50%): 11 minor, three mild, and five severe. Spontaneous ankylosis developed in 28 feet (73.7%). Nine feet (23.7%) required arthrodesis for symptomatic arthritis of the ankle or midfoot and deformity that could not be treated with orthoses. Conclusion: The Ilizarov external fixator allows simultaneous correction of all the severe foot deformities associated with neglected clubfoot with minimal surgery, reducing risks of cutaneous or neurovascular complications and avoiding excessive shortening of the foot. Even in those patients in whom final corrective arthrodesis is necessary, this may be carried out with minimal bone resection, since the severe deformities of the foot and ankle have been corrected.

Plantar fasciitis is a very common painful syndrome, but its exact etiology still remains obscure. The diagnosis is essentially clinical, based on history-taking and physical examination. Complementary laboratory tests and imaging examinations may be useful for differential diagnoses. The treatment is essentially conservative, with a high success rate (around 90%). The essence of the conservative treatment is the home-based program of exercises to stretch the plantar fascia. Indications for surgical treatment are only made when the symptoms persist without significant improvement, after at least six months of conservative treatment supervised directly by the doctor.A fascite plantar é uma síndrome dolorosa muito frequente, mas sua exata etiologia ainda permanece obscura. O diagnóstico é essencialmente clínico e tem como base a história e o exame físico. Exames complementares laboratoriais e de imagem podem ser úteis no diagnóstico diferencial. O tratamento é essencialmente conservador, com elevada taxa de sucesso (ao redor de 90%). A essência do tratamento conservador é o programa domiciliar com exercícios para alongamento da fáscia plantar. A indicação do tratamento cirúrgico somente é feita quando os sintomas persistem sem melhoria significativa, após pelo menos seis meses de tratamento conservador supervisionado diretamente pelo médico.

ResumoObjetivoavaliar os resultados em longo prazo da reconstrução do antepé nos pacientes com artrite reumatoide submetidos à artrodese da articulação metatarsofalângica (MTF) do hálux, artroplastia de ressecção das cabeças dos metatarsos laterais e correção das deformidades nos dedos menores por meio de artrodese da articulação interfalângica proximal (IFP) ou manipulação fechada.Métodosforam estudados retrospectivamente 17 pacientes (27 pés) submetidos à cirurgia de reconstrução do antepé com artrodese da primeira articulação MTF, ressecção das cabeças dos metatarsos laterais e correção das deformidades nos dedos menores. O seguimento médio foi de 68 meses (12 a 148), a média de idade foi de 52 anos (20 a 75 meses) e quatro pacientes eram do sexo masculino e 13 do feminino.Resultadosos resultados foram classificados como excelente em 17 pés, bom em dois, regular em quatro e ruim em dois. A pontuação média da escala Aofas (American Orthopaedic Foot and Ankle Society) foi de 70 pontos, 21 pés (78%) encontravam‐se assintomáticos e seis (22%) apresentavam algum tipo de sintoma. Três pés apresentaram pseudoartrose. Um deles foi submetido à revisão da artrodese com sucesso. Não houve diferença significativa na pontuação da escala Aofas e nos índices de consolidação com o uso de placa e parafusos ou fios de Kirschner na fixação da artrodese.Conclusãoa artrodese da primeira articulação MTF com artroplastia de ressecção das cabeças dos metatarsos laterais e correção das deformidades nos dedos menores, usada na reconstrução do antepé dos pacientes reumatoides, demonstrou bons resultados em longo prazo, com elevado índice de satisfação dos pacientes e melhoria clínico‐funcional.AbstractObjectiveto evaluate the long‐term results from reconstruction of the forefoot in patients with rheumatoid arthritis who underwent arthrodesis of the metatarsophalangeal joint of the hallux, resection arthroplasty of the heads of the lateral metatarsals and correction of the deformities of the smaller toes through arthrodesis on the proximal interphalangeal joint or closed manipulation.Methodsseventeen patients (27 feet) who underwent forefoot reconstruction surgery by means of arthrodesis of the first metatarsophalangeal joint, resection of the heads of the lateral metatarsals and correction of the deformities of the smaller toes, were studied retrospectively. The mean follow‐up was 68 months (12 to 148 months); the mean age was 52 years (range: 20 to 75 months); and four patients were male and 13 were female.Resultsthe results were classified as excellent in 17 feet, good in two, fair in four and poor in two. The mean score on the AOFAS scale was 70 points; 21 feet (78%) were found to be asymptomatic; and six feet (22%) presented some type of symptom. Three feet presented pseudarthrosis, and one of these successfully underwent revision of the arthrodesis. There was no significant difference in scoring on the AOFAS scale or in the consolidation rate, between using a plate and screws and using Kirschner wires for fixation of the arthrodesis.Conclusionarthrodesis on the first metatarsophalangeal joint with resection arthroplasty on the heads of the lateral metatarsals and correction of the deformities of the smaller toes, which was used in forefoot reconstruction in rheumatoid patients, showed good long‐term results with a high satisfaction rate among the patients and clinical‐functional improvement.

ResumoA fascite plantar é uma síndrome dolorosa muito frequente, mas sua exata etiologia ainda permanece obscura. O diagnóstico é essencialmente clínico e tem como base a história e o exame físico. Exames complementares laboratoriais e de imagem podem ser úteis no diagnóstico diferencial. O tratamento é essencialmente conservador, com elevada taxa de sucesso (ao redor de 90%). A essência do tratamento conservador é o programa domiciliar com exercícios para alongamento da fáscia plantar. A indicação do tratamento cirúrgico somente é feita quando os sintomas persistem sem melhoria significativa, após pelo menos seis meses de tratamento conservador supervisionado diretamente pelo médico.AbstractPlantar fasciitis is a very common painful syndrome, but its exact etiology still remains obscure. The diagnosis is essentially clinical, based on history‐taking and physical examination. Complementary laboratory tests and imaging examinations may be useful for differential diagnoses. The treatment is essentially conservative, with a high success rate (around 90%). The essence of the conservative treatment is the home‐based program of exercises to stretch the plantar fascia. Indications for surgical treatment are only made when the symptoms persist without significant improvement, after at least six months of conservative treatment supervised directly by the doctor.