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- The Ankle Instability Treatment: a Shift in Paradigm?Publication . Machado, M; Balulal, J; Amado, PDespite being the most frequent sports injury worldwide, ankle instabilitry has received very little attention over the years from evidence-based medicine, a trnd that has only been contered in recent years. Several papers have been published that might change the paradigm of the treatment patients in with ankle instability, so it is paramount important that surgeons keep up to date with the best high quality available. This study intends to be an alert to that fact and guide for the search of the newest information.
- Instabilidade Subtalar: uma Entidade Subdiagnosticada?Publication . Machado, M; Barreira, M; Pereira, B; Andrade, R; Espregueira-Mendes, JA instabilidade subtalar continua a ser um tópico controverso e a sua causa está ainda por conhecer. O mecanismo de lesão e os sintomas clínicos da instabilidade do tornozelo e da instabilidade subtalar sobrepõem-se, resultando muitas vezes em casos de instabilidade subtalar, isolada ou combinada, que não são corretamente diagnosticados. Negligenciar a instabilidade subtalar associada à instabilidade do tornozelo pode levar à falência do tratamento conservador e à evolução para instabilidade crónica com necessidade de tratamento cirúrgico. A compreensão da anatomia e da biomecânica da articulação subtalar é crucial para o diagnóstico correto desta patologia e posterior escolha do tratamento mais adequado. Esta revisão narrativa pretende percorrer à literatura mais recente, de forma a tornar percetível o estado de arte sobre esta entidade, desde a sua anatomia e biomecânica, aos métodos de diagnóstico e, finalmente, aos tipos de tratamentos existentes ao dia de hoje.
- Trotinetes Elétricas – É Urgente RegulamentarPublication . Machado, M; Diogo, N
- Osteomielitis Hematógena Aguda en Lisboa: Asociación con Miositis y Artritis Inesperadamente AltaPublication . Gouveia, C; Branco, J; Norte, S; Arcangelo, J; Alves, P; Pinto, M; Tavares, DIntroduction: Despite the current trend towards less aggressive therapeutic approaches, acute haematogenous osteomyelitis (AHO) continues to be a challenge and is associated with significant morbidity worldwide. Our aim was to determine if 80% compliance with current protocol was achieved, identify complications and associated risk factors and analyse trends in aetiology and management of AHO in children. Methods: We conducted a longitudinal, observational, single-centre study in patients with AHO aged less than 18 years admitted to a paediatric hospital, between 2008 and 2018, divided into 2 cohorts (before and after 2014). Demographic, clinical data and disease progression were analysed. Results: The study included 71 children with AHO, 56% male, with a median age of 3 years (interquartile range, 1-11). We found a 1.8-fold increase of cases in the last 5 years. The causative agent was identified in 37% of cases: MSSA (54%), MRSA (4%), Streptococcus pyogenes (19%), Kingella kingae (12%), Streptococcus pneumoniae (8%), and Neisseria meningitidis (4%). Complications were identified in 45% of patients and sequelae in 3.6%. In recent years, there was an increase in myositis (30% vs. 7%; p=0.02), septic arthritis (68% vs. 37.2%; p=0.012) and in the proportion of patients treated for less than 4 weeks (37% vs. 3.5%; p=0.012), with a similar sequelae rates. The risk factors for complications were age 3 or more years, CRP levels of 20mg/l or higher, time elapsed between onset and admission of 5 or more days and positive culture, although on multivariate analysis only positive culture was significant. The presence of complications was a risk factor for sequelae at 6 months. Conclusions: Our study confirms that AHO can be aggressive. The identification of risk factors for complications may be fundamental for management.
- Sternoclavicular Joint Septic Arthritis in a Healthy Adult: a Rare Diagnosis with Frequent ComplicationsPublication . Barbeiro Gonçalves, R; Grenho, A; Correia, J; Reis, JEWe report a case of complicated sternoclavicular joint septic arthritis in a previously healthy adult with no risk factors. An 83-year-old female presented to the emergency with a 1-week history of right shoulder pain followed by fever and prostration in the last 48 h. Computed tomography (CT) scan findings were consistent with right sternoclavicular joint (SCJ) septic arthritis complicated by periarticular abscess. Emergent surgical debridement was performed by a surgical team composed of orthopaedic and thoracic surgeons, followed by 6 weeks of antibiotic treatment. This case highlights the diagnosis and surgical treatment of a rare septic arthritis location but with frequent complications as well as the importance of multidisciplinary collaboration.
- Validation of the Ottawa Ankle Rules: Strategies for Increasing SpecificityPublication . Morais, B; Branquinho, A; Barreira, M; Correia, J; Machado, M; Marques, N; Ferrão, A; Nóbrega, J; Teixeira, F; Diogo, NIntroduction: The majority of patients with ankle injuries undergo radiological examinations of the foot, ankle or both. The objective of this study was in the first place to validate the Ottawa Ankle Rules (OARs) for the population of our centre. Secondly, an attempt was made to identify parameters that contribute to improve the specificity of the method, with a view to reduce the need for patients to be exposed to radiation as well as optimizing the expenses of the Emergency Ward (EW). Materials and methods: This was a prospective study conducted during a 9-month period. The study population included 148 patients, in 54 (36%) of the patients a fracture was present on the exams performed. Patients were submitted to a sequential protocol in the EW with a form completion, evaluation of OARs, application of the Visual Analog Pain Scale (VAS) and radiographic exams. Results: We found a sensitivity of OARs in ankle injuries of 100%, specificity of 26% and in midfoot injuries of 100% and 62% respectively. All patients with fractures had a VAS of 5 or more points in any of the tested sites. With the VAS criterium, we found a significant increase of global specificity (38% vs 15%), as well as when applied only to the ankle (26% to 47%) or to midfoot trauma (62% to 67%). In both, there would have been a 100% reduction of CT scans. Patients with a fracture or with fractures who required surgical treatment had a mean VAS significantly higher than patients with no fracture or fractures submitted to conservative treatment respectively. Although there was a lower percentage of fractures in the group of injuries in Work Accidents (31% vs 37% Sports Activity and 38% Leisure Activity), there was a statistically significant increase in the sum of average VAS in Accidents at Work vs Leisure Activities and vs Sports Activities. Conclusion: We seek to confirm the usefulness of OARs for our population and we investigated strategies to further reduce the need for unnecessary radiographs. The introduction of parameters for grading pain and adapting to the context of the accident seem promising
- Trapeziectomy with Suture-Button Suspensionplasty Versus Ligament Reconstruction and Tendon Interposition: a Randomized Controlled TrialPublication . Morais, B; Botelho, T; Marques, N; Nóbrega, J; Ferrão, A; Jorge, J; Teixeira, FThe purpose of the present study was to compare the results of patients operated with trapeziectomy and ligament reconstruction and tendon interposition (LRTI) using flexor carpi radialis tendon versus trapeziectomy followed by suspension of the first metacarpal to the second metacarpal using a Mini TightRope® suture button (suture button suspension: SBS). A single-center prospective randomized controlled trial was performed, comparing 37 patients with SBS and 39 with LRTI. All surgeries were performed by the same fellowship-trained hand surgeon. Patients were assessed by an independent observer at 40 months' follow-up. Pre- and postoperative strength, trapezial space ratio (TSR), range of motion, QuickDASH and visual analogue pain score were recorded. Both procedures improved functional parameters of pain, key strength, tip strength and grip strength while maintaining range of motion, without significant differences. In the SBS group, TSR decreased by 17%, compared to 28% in the LRTI group. The mean operative time was shorter in SBS (63 vs 91 minutes; p < 0.0001), as was immobilization time (2 vs 6 weeks; p < 0.0001), and patients resumed normal activity sooner (10 vs 12 week; p = 0.0138) and required less physical therapy (19.3 vs 13.1 weeks; p < 0.0001). We believe that our results are related to the hypothesis suggested by biomechanical studies that revealed better initial load bearing profile and maintenance of trapezial space following serial loading in cadaver models.
- Is Bilateral Hallux Valgus Chevron Osteotomy a Safe Procedure for Ambulatory Surgery?Publication . Morais, B; Botelho, T; Marques, N; Ferrão, A; Nóbrega, J; Teixeira, F; Grenho, AIntroduction: Several osteotomies of the first metatarsal have been described for treatment of hallux valgus but chevron osteotomy is one of the most common and well-established procedure for treating this deformity. Although there is a trend towards considering bilateral surgery there is lack of publications addressing bilateral treatment in ambulatory units. The aim of this study is to analyze results of bilateral and unilateral distal chevron osteotomies associated with lateral soft tissue release as ambulatory procedures. Materials and methods: A retrospective review was made about the patients treated at our ambulatory unit over a period of five years. Initially, general information as patient's satisfaction's rate and return to normal activity's time and evaluation of standardized follow-up charts and records made by the surgeon were recorded. Secondly, the hallux metatarsophalangeal interphalangeal scale developed by the American Orthopedic Foot & Ankle Society was used. Results: A total of 194 patients with 230 feet operated were included in this study. We found 29 patients that didn't meet the inclusion criteria and were excluded. The unilateral group was composed by 139 feet and the bilateral group by 52 feet. The improvement between preoperative and discharge clinical and radiographic results was significant independently in both groups. A total of 14% of complications were found in our study, 19% in the unilateral group and 12% at the bilateral group. None of them required revision surgery. Conclusion: Bilateral distal chevron osteotomies, associated with lateral soft tissue release, are safe and effective ambulatory procedures. It was found a satisfactory deformity correction in moderate HV. Both patients that underwent unilateral and bilateral procedures had similar clinical and radiological outcomes with no increase in complications or return to normal activity time. With this study it was demonstrated that bilateral chevron osteotomies can be performed as ambulatory procedures.
- A Giant Hand Lipoma As a Rare Cause of Secondary Carpal Tunnel Syndrome - a Case ReportPublication . Barreira, M; Marques, N; Campos, V; Marques, G; Gonçalves, S; Stefanova Alves, SIntroduction: Lipomas are a rare cause of compressive neuropathy and they lead to atypical clinical presentation that can mimic carpal tunnel syndrome. Case presentation: The authors describe a rare presentation of a carpal tunnel syndrome recurrence after a hand giant lipoma, presenting with rapidly compression neuropathy of the median nerve, 6 months after de primary surgery. Discussion: Lipomas are common benign soft tumours. Their occurrence in the hand remains rare and they rarely cause secondary entrapment neuropathies. Carpal tunnel syndrome is mostly idiopathic and bilateral. Local factors should be suspected when these neuropathies present with atypical symptomatology or even when they recur after primary conventional surgical release. Investigation should consider images studies as this correct preoperative assessment leads to successful diagnosis and treatment.
- Como Retomar a Atividade Cirúrgica Eletiva em Ortopedia Durante a Pandemia COVID-19?Publication . Diogo, N; Miranda, A; Ruano, A; Mendes, E; Mendes, F; Montes, J; Alves, J; Rosa, I; Alegrete, N; Neves, N; Lourenço, P; Felicíssimo, P; Sá Cardoso, P; Gomes, AEste documento foi elaborado pelo Colégio de Ortopedia da Ordem dos Médicos com o objetivo de estabelecer as orientações sobre a retoma da atividade cirúrgica programada em Ortopedia durante a pandemia COVID-19. As presentes normas de orientação: a) definem os critérios que permitem a priorização das cirurgias de acordo com a gravidade da situação clínica, com base em classificações existentes e publicadas; b) fornecem um modelo de organização para a preparação dos doentes, descrevendo os circuitos do doente nos períodos pré-operatório, intraoperatório e pós-operatório; c) realçam as regras de segurança para a realização de cirurgias e desenham um modelo de acompanhamento após a alta de acordo com a evidência científica.