Rate of complications due to neuromuscular scoliosis spine surgery in a 30-years consecutive series.

PURPOSE: The aim of this study was to evaluate the rate of intraoperative and postoperative complications in a large series of patients affected by neuromuscular scoliosis. METHODS: It was a monocentric retrospective study. In this study have been considered complications those events that significantly affected the course of treatment, such as getting the hospital stay longer, or requiring a subsequent surgical procedure, or corrupting the final result of the treatment. RESULTS: Of the 358 patients affected by neuromuscular scoliosis treated from January 1985 to December 2010, 185 that met the inclusion criteria were included in the study. There were recorded 66 complications in 55/185 patients. Of that 66 complications, 54 complications occurred in 46/120 patients with Luque's instrumentation, while only 12 complications occurred in 9/65 patients with hybrid instrumentation and this difference was statistically significant (p < 0.05); 11/126 patients with pelvic fixation and 5/59 without pelvic fixation, as well as 45/156 patients treated by posterior approach alone and 10/29 patient that underwent combined anterior-posterior approach suffered complications but both this did not result in a statistical significant difference (p > 0.05). CONCLUSIONS: The surgical treatment in neuromuscular scoliosis is burdened by a large number of complications. An accurate knowledge of possible complications is mandatory to prepare strategies due to prevent adverse events. A difference in definitions could completely change results in good or bad as well as in our same series the adverse events amounted at almost 30% of cases, but complications that due to complete failure would amount at 9.19% of patients.

Efficacy of the assisted self-reduction technique for acute anterior shoulder dislocation.

INTRODUCTION: The "original" traction-free Kocher's method to perform the reduction of shoulder dislocation has been recently reviewed and some authors speculated that it can be self performed by patients under the guide of the physician. In this way, as an "assisted self-reduction" technique, it is also effective and simple to perform. The aim is to study the effectiveness of the assisted self-reduction technique, in comparison to the well known and largely used traction-countertraction method. MATERIALS AND METHODS: From a consecutive series of 237 uncomplicated anterior shoulder dislocations, a total of 61 were managed by the residents of our institution under the supervision of the senior authors using the assisted self-reduction method and 176 were managed by other orthopaedic consultants on duty in the Emergency Department using the traction-countertraction technique. Only the senior authors used the assisted self-reduction technique, whereas the other orthopaedic consultants used the traction-countertraction method. The need for intravenous sedation or general anaesthesia to perform the assisted self-reduction was considered a failure. Recorded variables were demographic data, previous dislocation, traumatic mechanism and medication use during shoulder reduction, time to perform the reduction. RESULTS: Ninety-eight percent of the acute dislocation treated with the assisted self-reduction technique and 81 % treated with the traction-countertraction method were reducible without recourse to intravenous sedation. CONCLUSIONS: The assisted self-reduction technique is simple, effective and gentle. Physicians on duty in the Emergency Departments should therefore be encouraged to use it.

Chest pain caused by multiple exostoses of the ribs: A case report and a review of literature.

The aim of this paper is to report an exceptional case of multiple internal exostoses of the ribs in a young patient affected by multiple hereditary exostoses (MHE) coming to our observation for chest pain as the only symptom of an intra-thoracic localization. A 16 years old patient with familiar history of MHE came to our observation complaining a left-sided chest pain. This pain had increased in the last months with no correlation to a traumatic event. The computed tomography (CT) scan revealed the presence of three exostoses located on the left third, fourth and sixth ribs, all protruding into the thoracic cavity, directly in contact with visceral pleura. Moreover, the apex of the one located on the sixth rib revealed to be only 12 mm away from pericardium. Patient underwent video-assisted thoracoscopy with an additional 4-cm mini toracotomy approach. At the last 1-year follow-up, patient was very satisfied and no signs of recurrence or major complication had occured. In conclusion, chest pain could be the only symptom of an intra-thoracic exostoses localization, possibly leading to serious complications. Thoracic localization in MHE must be suspected when patients complain chest pain. A chest CT scan is indicated to confirm exostoses and to clarify relationship with surrounding structures. Video-assisted thoracoscopic surgery can be considered a valuable option for exostoses removal, alone or in addiction to a mini-thoracotomy approach, in order to reduce thoracotomy morbidity.

Arthroscopic Treatment of 2 Consecutive Cases of Dysplasia Epiphysealis Hemimelica of the Ankle: A 5-Year Follow-Up Report.

The dysplasia epiphysealis hemimelica (DEH) is a rare disease of unknown etiology consisting in an abnormal osteocartilaginous growth at the epiphysis, usually hemimelic with histological findings similar to benign osteochondroma. In this case series, we described the results of the arthroscopic treatment of 2 consecutive cases of intra-articular ankle localization of DEH in 2 patients aged 9 and 10 years. The good result obtained, persistent at the 5-year follow-up, leads us to consider the arthroscopic approach as a reliable treatment in patient affected by intra-articular ankle DEH.

Impaired primary hemostasis with normal platelet function in Duchenne muscular dystrophy during highly-invasive spinal surgery.

A defective, normal or enhanced hemostasis has been reported in Duchenne muscular dystrophy (DMD). A retrospective analysis of intra-and postoperative (up to 36 h) estimated blood losses was performed in 156 patients undergoing spinal surgery for: DMD (n = 31), idiopathic scoliosis (IS) (n = 70), poliomyelitis (n = 10), cerebral palsy (CP) (n = 28), spinal muscular atrophy (SMA) (n = 17). Platelet aggregation and bleeding times were also investigated in DMD patients. Immunohistochemistry for dystrophin was performed in platelets, megakaryocytes and blood vessels of normal tissues. DMD patients showed significantly higher intraoperative estimated blood losses (DMD: 3495+/-890 ml; IS: 2269+/-804 ml; poliomyelitis: 2582+/-1252 ml; CP: 2071+/-683 ml; SMA: 2464+/-806 ml; P < 0.05), while postoperative blood losses were similar among different groups. Higher estimated blood losses in DMD were independent of the duration of surgery, body weight, gender, age, vertebral levels or preoperative Cobb angle. DMD children had significantly prolonged bleeding times, but retained normal platelet function. From control samples dystrophin was expressed in vascular smooth muscle cells, but not in platelets. DMD appears to be characterized by immediate bleeding during highly-invasive surgery and increased bleeding time without platelet abnormalities. Considering dystrophin expression in normal vascular smooth muscle cells, these results altogether suggest a selective defect of primary hemostasis in DMD, likely to be due to impaired vessel reactivity.

Isolated asymptomatic short sternum in a healthy young girl.

Congenital sternal defects are rare deformities frequently associated with other anomalies of the chest wall and other organ systems. Although pectus excavatum, pectus carinatum, and cleft sternum can present as isolated deformity, in most cases they are associated with heart and inner organs anomalies and described as symptoms of syndromes like Marfan syndrome, Noonan syndrome, Poland anomaly, and Cantrell pentalogy. In contrast, the etiology of an isolated defect is not well understood. We observed a short sternum (dysmorphic manubrium, hypoplastic body, and complete absence of the xiphoid process) in a completely asymptomatic 13-year-old woman. A comprehensive instrumental exams panel was performed to exclude associated anomalies of the heart and of the other organ systems. The patient was completely asymptomatic and she did not need any medical or surgical treatment. To our knowledge, this is the first case of isolated short sternum reported in literature.

Osteomyelitis caused by Pantoea agglomerans in a closed fracture in a child.

Development of osteomyelitis in a closed fracture is rare. Although it has been reported that trivial trauma may be associated with the subsequent development of acute osteomyelitis, no evidence has been found that fractures are involved in the etiology of osteomyelitis. Only 25 cases (11 in adolescents) of osteomyelitis after closed fracture have been reported in literature. The authors report a case of osteomyelitis in an 8-year-old girl after a forearm fracture involving the diaphysis of the radius and ulna. Radiographic examinations were performed 5, 14, and 30 days after trauma. At last examination, the forearm appeared swollen and red. Blood culture and radiographs confirmed the clinical suspicion of osteomyelitis. The cultures grew Pantoea agglomerans, a saprophytic gram-negative bacterium commonly isolated from plants, flowers, seeds, water, and soil and sensitive to all of the most common antibiotics. After the arm was immobilized, high doses of intravenous antibiotics were administered for 4 weeks, and oral antibiotics were prescribed for an additional 4 weeks. The patient responded well to treatment. Twelve months after the initial injury, the patient regained full elbow and wrist flexion-extension range of motion. Based on their experience and a review of the literature, the authors suggest that bone infection be considered for patients with closed fractures complicated by excessive or prolonged pain and swelling with evident signs of inflammation where no other obvious infection is apparent. Moreover, in children, bacterial infection may cause osteomyelitis more frequently than in adults, but no evidence exists that a closed fracture increases the incidence of osteomyelitis in children with a systemic infection.

Aneurysmal bone cysts: treatment with direct percutaneous Ethibloc injection: long-term results.

PURPOSE: To assess the efficacy and long-term results of Ethibloc treatment in aneurysmal bone cysts (ABC). METHODS: Thirteen patients with ABC were treated with direct percutaneous Ethibloc injection. Four patients had only one injection and the other nine patients from two to four injections. No severe complications were observed; in two patients a local leakage of Ethibloc from the cyst into the soft tissues occurred but it was temporary and the consequent inflammation self-healed without residua and sequelae. Imaging follow-up lasted from 6 to 67 months and included conventional radiology (CR) and magnetic resonance imaging (MRI), both used in the presurgical phase. RESULTS AND CONCLUSIONS: All images demonstrated a remarkable shrinkage of the cystic lesion and bone cortex thickening. In all patients, circumscribed areas of lucency persisted at radiography, corresponding to residual cystic areas without fluid-fluid levels at MRI. Pain, which was present in all the patients before treatment, was relieved within a month. According to our experience, direct percutaneous Ethibloc injection is effective in the treatment of ABC and can be recommended as the first-choice treatment. Due to its higher sensitivity MRI must be included either in the pretreatment phase to study the multilocular structure or in the imaging follow-up to evaluate the efficacy of Ethibloc in persistently non-responsive areas.