Informed Consent: Legal Obligation or Cornerstone of the Care Relationship?

The topic of informed consent has become increasingly important in recent decades, both in the ethical-deontological field and as a duty of law. The review covered all sentences issued by the 13th section of the Civil Court of Rome during the period January 2016-December 2020. During this period, 156 judgments were found in which a breach of consent was required; in 24 of these, specific liability was proven, and the corresponding compensation liquidated. Moreover, 80% of the cases concerned the lack of information provided. The most involved branches were those related to surgical areas: general surgery, plastic surgery and aesthetic medicine and orthopaedics. The total amount of compensation paid was EUR 287,144.59. The research carried out has highlighted how, in a broad jurisprudential context, the damage caused by the violation of the right related to informed consent is considered, and how it impacts on the economic compensation of damages. Additionally, it showed that the areas most affected by the information deficit are those related to the performance of surgical activities, which are characterized by greater invasiveness and a higher risk of adverse events. The data reported underline the exigency to consider informed consent not as a mere documentary allegation but as an essential moment in the construction of a valid therapeutic alliance, which is also useful for avoiding unnecessary litigation that is becoming increasingly burdensome for healthcare systems all over the world.

Clinical and Radiological Results after Fracture-Dislocations of the Ankle: A Medium- to Long-Term Followup Study.

The authors report the long-term outcome in a series of 26 patients surgically treated for a fracture-dislocation of the ankle by open reduction and internal fixation (ORIF), reviewed after an average followup of 5.2 years. The average age of the patients was 46.8 years; 17 were female and 9 male; the right side was involved in 22 patients and the left side in 4; 10 patients had a unimalleolar fracture, 11 a bimalleolar fracture, and 5 a trimalleolar fracture. The quality of reduction was excellent in 14 cases and good in 12. The functional results were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) score, while radiographic results followed the Van Dijk classification. At followup, the AOFAS score ranged from 75 to 98 points with an average of 87.9, while the radiographic results were evaluated as grade 0 in 16 ankles and grade I in 10. Fracture-dislocations of the ankle occurred more frequently after high-energy traumas in younger patients on the right side, but they were also observed in older females after low-energy trauma. Excellent reduction was correlated with better radiographic results at long term followup. However, these injuries may lead to a poor functional outcome, despite an anatomical reduction and good radiographic results; in fact, in nine of our cases (34.6 percent), the AOFAS score was less than 90 points.

Surgical Treatment of Severe Idiopathic Flexible Flatfoot by Evans-Mosca Technique in Adolescent Patients: A Long-Term Follow-Up Study.

Flexible idiopathic flatfoot is very common in growing age and rarely causes pain or disability. Surgery is indicated only in severe symptomatic cases that are resistant to conservative treatment, and numerous surgical procedures have been proposed. Lateral column calcaneal lengthening as described by Evans and modified by Mosca is a widely used surgical technique for the correction of severe symptomatic flexible flatfoot. In the present study, we report the long-term clinical and radiographic results in 14 adolescent patients (mean age: 12.8 years) affected by severe symptomatic flexible flatfoot, surgically treated by Evans-Mosca procedure, for a total of 26 treated feet (12 cases bilateral and 2 unilateral). In all cases, surgery was indicated for the presence of significant symptoms resistant to nonsurgical management. Clinical evaluation was made according to the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, the Foot and Ankle Disability Index (FADI) Score, and Yoo et al.'s criteria. Radiographic evaluation was made using anteroposterior and lateral weight-bearing radiographs of the feet to evaluate Meary's angle and Costa-Bertani's angle and to evaluate possible osteoarthritic changes in the midtarsal joints. At follow-up (mean: 7 years and 7 months), we observed a satisfactory result in all patients. The mean average score of the AOFAS Ankle-Hindfoot Scale improved from 60.03 points to 95.26; the mean FADI score improved from 71.41 to 97.44; and according to Yoo et al.'s criteria, the average clinical outcome score was 10.96. At radiographic examination, nonunion of the calcaneal osteotomy was never observed. Meary's angle improved from an average preoperative value of 25° to 1.38° at follow-up; Costa-Bertani's angle improved from an average preoperative value of 154.2° to 130.9° at follow-up. In no case, significant radiographic signs of midtarsal joint arthritis were observed. According to our results, we believe that Evans-Mosca technique is a valid option of surgical treatment for severe idiopathic flexible flatfoot and allows a satisfactory correction of the deformity with a low rate of complications.

Synovial cyst of the acromioclavicular joint with and without rotator cuff tear: A case series of two patients.

INTRODUCTION: Acromioclavicular joint cyst (AJC) is a very uncommon condition of the shoulder observed in elderly patients, caused by a degenerative acromioclavicular (AC) joint, frequently associated to a rotator cuff tendon tear. There are two possible cause for the cyst formation. We report two different cases of a AC synovial cyst, with and without rotator cuff tear. PRESENTATION OF CASES: We report two cases, in patients aged respectively 80 and 77 years, with a very large AJC. In one case, the cyst was associated to a rotator cuff tear, while in the other case, the rotator cuff did not present any evident lesion. Both cysts were successfully surgical excised and a distal clavicle resection was performed. DISCUSSION: AJC is a rare complication observed in degenerative AC joint and in the majority of cases is associated to a rotator cuff tear. The diagnosis may be made by ultrasound and conventional radiographic examination, although MRI of the shoulder is generally preferred as it allows to better identify the condition of the rotator cuff. Generally, local aspiration of the cyst and corticosteroid injection fails with recurrence of the cyst and surgically treatment is indicated, especially in painful cases. CONCLUSION: Painful AJC should be surgically treated by excision of the cyst associated to a lateral clavicle resection; when a symptomatic massive rotator cuff is present, a reverse total shoulder arthroplasty may be considered. However, in elderly patients, who have no discomfort, watchful waiting may be the treatment of choice.

Intraoperative Disinfection by Pulse Irrigation with Povidone-Iodine Solution in Spine Surgery.

BACKGROUND: Deep wound infection in spine surgery is a debilitating complication for patients and increases costs. The objective of this prospective study was to evaluate the efficacy of wound pulse irrigation with a dilute povidone-iodine solution in the prevention of surgical site infection. METHODS: 50 patients undergoing spinal surgery were randomly divided into two groups (A and B) of 25 patients each. In group A, wounds were irrigated with dilute (3%) povidone-iodine solution through a low-pressure pulsatile device. In group B, wounds were irrigated with saline solution through a bulb syringe. In both groups, specimens for bacterial culture were harvested from surgical site before and after irrigation. RESULTS: In group A, no surgical site infection occurred; in group B, deep wound infection was observed in 3 patients. In both groups, before irrigation some cultures have been found positive for bacterial contamination. CONCLUSION: Our study seems to support the idea that low-pressure pulsating lavage of surgical wounds with povidone-iodine diluted to a nontoxic concentration of 3% is an effective therapeutic adjunct measure to prevent surgical site infection in spine surgery. However, the number of the enrolled patients is small and a significant statistical analysis is not practicable. This trial is registered with NCT03249363.

Orthopaedic Aspects of Marfan Syndrome: The Experience of a Referral Center for Diagnosis of Rare Diseases.

Marfan syndrome is caused by mutations in the fibrillin-1 gene (FBN1). The most important features affect the cardiovascular system, eyes, and skeleton. The aim of this study was to report the most frequent musculoskeletal alterations observed in 146 patients affected by Marfan syndrome. Fifty-four patients (37%) underwent cardiac surgery and 11 of them received emergent surgery for acute aortic dissection. Ectopia lentis was found in 68 patients (47%) whereas myopia above 3D occurred in 46 patients (32%). Musculoskeletal anomalies were observed in all patients with Marfan syndrome. In 88 patients (60.2%), the associated "wrist and thumb sign" was present; in 58 patients (39.7%), pectus carinatum deformity; in 44 patients (30.1%), pectus excavatum; in 49 patients (33.5%), severe flatfoot; in 31 patients (21.2%), hindfoot deformity; in 54 patients (36.9%), reduced US/LS ratio or increased arm span-height ratio; in 37 patients (25.3%), scoliosis or thoracolumbar kyphosis; in 22 patients (15%), reduced elbow extension (170° or less). Acetabular protrusion was ascertained on radiographs in 27 patients (18.4%). Orthopaedic aspects of the disease are very important for an early diagnosis; however, we have not observed definite correlations between the extent of orthopaedic involvement and aortic complications.

Surgical repair of isolated triceps tendon rupture using a suture anchor technique: a case report.

Rupture or avulsion of the distal triceps tendon is one of the least common tendon injuries. The most common clinical presentation of the injury is avulsion from the olecranon. The diagnosis of acute triceps tendon rupture may be missed and this can result in prolonged disability. We report the case of a 42-year-old man with isolated triceps rupture treated by an open surgical repair technique involving the use of bone suture anchors.

Post-traumatic malunion of the proximal phalanx of the finger. Medium-term results in 24 cases treated by "in situ" osteotomy.

We report the clinical and radiographic medium-term results obtained for 20 patients (24 fingers) treated surgically for post-traumatic malunion of the proximal phalanx of the finger. In all cases we performed a corrective osteoclasia or osteotomy at the site of malunion, followed by miniplate and screw fixation or by screw fixation only. The corrective osteoclasia was performed when malalignment was addressed within six weeks after injury. Two patients who had two fractures underwent additional surgery (tenolysis and/or capsulolysis) to improve function and ROM. At the final follow-up, at a mean of 24 months after corrective surgery, good or excellent clinical and radiographic results were obtained in all the patients. The pseudoclaw deformity disappeared in all cases in which a volar angulation deformity was present. An average improvement of about 30% in the range of motion of the MP and PIP joints was observed; only 4 patients complained of mild pain at the maximum degrees of articular excursion of the MP and PIP joints. All the patients presented an improvement in grip strength. The mean DASH score in our series was 5 points. In two of the four cases treated by an intra-articular corrective osteotomy, mild radiographic signs of osteoarthritis at the MP joint were present. The data for this study confirm that "in situ" osteotomy stabilized by miniplates and/or screws is an effective procedure to correct post-traumatic malunions of the proximal phalanges of the fingers.

Neglected fracture of the medial humeral epicondyle that was entrapped into the elbow joint: a case report.

The objective of this paper is to report clinical and radiographic long-term results of a neglected fracture of the medial humeral epicondyle, which was entrapped into the elbow joint. At follow-up, 48 years after the trauma, the patient complained of occasional discomfort around the elbow, but the joint had a normal range of motion and good stability. Radiographs showed that the epicondylar fragment was fused to the medial border of the olecranon. The authors conclude that an old fracture of the medial humeral epicondyle, presenting a fusion of the fragment to the olecranon with normal range of motion and without pain, may be managed expectantly.

Immediate continuous passive motion after internal fixation of an ankle fracture.

BACKGROUND: Surgical treatment is usually mandatory in displaced bimalleolar and trimalleolar fractures. Some authors have recommended early mobilization of the ankle joint after surgical treatment of these lesions. In this study, we evaluate the effect of immediate postoperative continuous passive motion in the management of displaced bimalleolar and trimalleolar fractures treated surgically. MATERIALS AND METHODS: Two series of 22 patients each, who had had a Weber type A, B or C ankle fracture treated surgically, were followed up at least 10 years after the injury. In the first series, immediately after surgery, a continuous passive motion machine was applied to the operated ankle for 3 weeks, whereas in the second series, after surgery a plaster splint or a plaster cast was applied for 3 weeks. RESULTS: At follow-up, all patients were evaluated clinically and radiographically using the AOFAS Ankle Hindfoot Score System (Kitaoka, Foot Ankle 15:349-353, 1994). The average final score for the first series of patients was 95.7 points (range 87-100 points, standard deviation 3.42 points). Of this series, at radiographic examination, in two patients we observed minor signs of osteoarthritis of the ankle joint. The average final score for the second series was 88 points (range 68-100 points, standard deviation 10.60 points). At radiographic examination, in six patients we observed minor signs of osteoarthritis of the ankle joint, whereas in another one the osteoarthritis was severe. CONCLUSIONS: Continuous passive motion started immediately after surgery seems to be an effective method both for allowing complete and quick recovery of the range of motion of the ankle and for reducing the risk of early degenerative joint disease. Immediate passive ankle motion can be applied only after adequate reduction and stable internal fixation.

Posterior spine fusion with Moss-Miami instrumentation for adolescent idiopathic scoliosis: radiographic, clinical and patient-centered outcomes.

This paper evaluates the efficacy the Moss-Miami System instrumentation for surgical treatment of spinal deformity. Eight-five patients with AIS underwent a posterior spinal fusion with using this system between 1994 and 1998. Radiographs of the spine were taken preoperatively, at discharge, one year after surgery, and at the latest follow-up (average of 2.5 year, range 2 to 6 years). All radiographs were assessed for curve magnitude, coronal balance, kyphosis, lordosis, junctional kyphosis, and sagittal balance. The Scoliosis Research Society instrument was administered at the final follow-up. The average curve correction ranged from 53 to 65 percent. All patients showed solid fusion by final follow-up. Three patients required a second operation for complications related to their scoliosis; two patients showed a rod fracture without evidence of pseudoarthrosis or curve progression. Two transient neurological complications related to the surgery were observed. SRS results were favorable with regard to function and cosmetic appearance.