Management of gunshot wound to the lumbosacral spine in a 17-year-old girl without neurological impairment.

We report the case of a young girl (17-year-old) wounded by an accidental gunshot. The bullet entered through the skin midline over the navel area, passed through the stomach perforating the vena cava and, by breaking the right pedicle of L4, moved inside the vertebral canal (bridging the cauda equina) stopping just in front of the body of S2. Because of the sudden onset of acute abdomen due to a massive retroperitoneal hematoma, the patient underwent emergency explorative laparotomy with the evacuation of the hematoma and the suture of the perforated cava vein, the peritoneum, and the stomach. No neurological deficits were observed after the gunshot. Two weeks later, the patient underwent spinal surgery to remove the bullet from the spinal canal, which was performed successfully without any instrumentation and with no onset of new neurological signs and symptoms or surgery-related complications. Patient was discharged on day 9 after surgery in good general conditions.

Video-assisted anterior retroperitoneal approach to the lumbar spine. A minimally invasive technique improved by the use of an endoscopic camera to treat lumbar spinal diseases. Consideration over 269 patients.

We describe the technique we routinely use to perform the retroperitoneal anterior approach using a rigid endoscope coupled to a HDD screen to assist mini-open retroperitoneal anterior approach. Our experience was compared to those reported in the literature for the standard mini-open retroperitoneal approach. We retrospectively analyzed a total of 269 consecutive patients, 109 males and 160 females, underwent anterior lumbar approach in our department, using video-assisted anterior retroperitoneal approach to the lumbar spine. 202 patients had a single L5-S1 or L4-5 ALIF (75.09%), 14 patients received a double level ALIF (5.3%), while 53 patients underwent a double anterior and posterior approach (19.8%). The average preoperative VAS and Oswestry Disability Index (ODI) scores were 9.1±6.3 and 79.3±11.9. At least 16 months follow-up (from 16 months to 5 years), the average VAS and ODI values had improved to 1.6±1.5 and 13.1±13.2, respectively (p <0.05). The mean length of stay was 4.3±3.5 days. There were 6 major complications (2.2%) related to the approach: major vascular injuries (iliac vein injury) occurred in a total of 3 patients (1.1% of cases), whereas retrograde ejaculation occurred in 3 patients (2,75% of male cases in the series). No wound or deep infections occurred. In our opinion, this technique, compared with other mini-open approach, potentially reduces perioperative morbidity, length of surgery, surgical approach-related complications, and hospitalization.

Use of lordotic cages in L5-S1 Anterior Lumbar Interbody Fusion (ALIF) procedures

Anterior Lumbar Interbody Fusion (ALIF) has gained popularity in the last few years, thanks to its numerous advantages. Recently the use of lordotic cages has been described, allowing theoretically a better lordosis restoration of the lumbar disc space. We described the results obtained with the use of lordotic cages in 27 patients who underwent ALIF procedure for L5-S1 disc degenerative disease, in terms of segmental lordosis and global lumbar lordosis changes.

A survey on surgeon practice shows lack of consensus on the management of primary shoulder stiffness.

Shoulder stiffness is a condition of painful restriction in active and passive glenohumeral range of motion, which can arise spontaneously or as consequence of a known cause. Numerous therapeutic approaches are available; however, no consensus has been reached on the best algorithm for successful treatment. The aim of this study was to investigate local practice patterns regarding management of primary shoulder stiffness. Randomized controlled trials reporting results of shoulder stiffness treatment were collected and analyzed prior to study begin. Controversial elements in the treatment of primary shoulder stiffness were identified and a survey was created and administrated to clinicians participating at an annual national congress dedicated to shoulder pathologies and their treatment. 55 completed questionnaires were collected. Physical therapy was recommended by 98% of the interviewed. The use of oral corticosteroids was considered by 58% and injections of corticosteroids by 60%. Injective therapy with local anaesthetics was considered by 56% of the clinicians and acupuncture by 36%. 38% of the interviewed did never treat shoulder stiffness surgically. Various strategies to manage shoulder stiffness have been proposed and high-level evidence has been published. Numerous controversial points and a substantial lack of consensus emerged both from literature reviews and from this survey. The treatment of shoulder stiffness should be tailored to the patient's clinical situation and the stage of its pathology, aiming primarily at identifying risk factors for recurrence, reducing pain, restoring range of motion and function and shortening the duration of symptoms.

Bilateral THA in the same sitting for avascular necrosis of the head of the femur in sickle cell patient: our African experience.

Sickle cell anemia is protective against the malaria protozoan. The heterozygous form of the disease is not fatal, and may cause musculoskeletal disorders when sickling occurs, and small vessels are occluded. When the head of the femur is involved, this may result in hip arthritis, often bilateral, at a young age. This article describes three patients in whom bilateral total hip arthroplasty (THA) was performed in the context of a humanitarian mission in Togo, Africa.

Management of intraoperative contamination of anterior cruciate ligament graft.

The options after the intraoperative graft contamination include sterilizing and implanting the graft, rejecting the graft and isolating another one from the other knee, rejecting the graft and using an allograft. The survey was prepared in Google Forms®. Only fully and correctly completed survey questionnaires were considered and included in this study. In total, 41 questionnaires in the study reported contamination. For the surgeon, the risk of contaminating the graft during the surgery is 0.2%. The mean contamination rate is 1.2 accidents per whole career. The statistical significance was observed in correlation between years of specialization and several accidents (p<0.05). The graft contamination may be experienced by almost 30% of surgeons performing ACL reconstructions. Neither knowledge, nor experience and training can prevent an operating team from that situation. The only solution is to follow a strict protocol of graft preparation. According to the data gathered in this study, there is still no ideal protocol after the incident occurs.

Histological assessment of new bone formation with biomimetic scaffold in posterolateral lumbar spine fusion.

Spinal fusion procedures often require the use of bone grafts (autograft or allograft) to help bone healing and to increase stability. However, the application of autografts is frequently limited by donor site morbidity. In recent years, different synthetic bone substitutes have been introduced in the clinical practice to overcome these limitations. The purpose of this paper is to report a case where a biomimetic, synthetic and osteoconductive bone graft substitute was successfully implanted in a patient during lumbar spine arthrodesis. The case of a 58-year-old female subjected to lumbar spine arthrodesis with bone augmentation is described. The bone graft substitute RegenOss® (Finceramica, Faenza, Italy) was implanted during spinal arthrodesis. The successful bone integration was evaluated by X-rays. After 11 months, the patient underwent a second surgery due to spine imbalance; the debris of the bone graft was therefore collected and analyzed by macroscopic evaluation and by histology. The bone substitute was successfully implanted during a spinal arthrodesis procedure. Histologic evaluation of the removed bone graft debris showed the complete resorption of the implant and the formation of new bone, which was well integrated with the host bone. This bone substitute may represent a safe and effective alternative to autologous bone grafts, avoiding adverse events related to donor-site morbidity.

One-stage Bilateral Total Hip Arthroplasty in patient with sickle cell disease and previous Girdlestone procedure on the right side: First presentation in Togo.

80% of Sickle Cell Disease cases are estimated to be in Sub-Saharan Africa. It can lead to various acute and chronic complications and osteonecrosis of the femoral head is one of these. Girdlestone procedure is an option to treat osteonecrosis in patients who could not afford arthroplasty. We report here the first case of bilateral total hip arthroplasty in a patient with a previous Girdlestone procedure on the right side and an osteonecrosis of the femoral hip on the left side.

Clinical anatomy of the meniscus in animal models: pros and cons.

Nowadays, despite the possibility to use in vitro or computer models in research, animal models are still essential. Different animal models are available for meniscal repair investigation. Although a unique perfect model for the structure of the human's knee does not exist, the choice of the proper animal model is crucial for a correct research. The principal animal models in the meniscal repair are sheep, goats, pigs and dogs. Each of these has pros and cons for their utilization. Analysing each pro and con is essential for optimizing the choice of the animal model, which depends on the experimental question, avoiding unnecessary waste of resources and minimizing the animal suffering, according to the Russell and Burch's three "Rs" principles (Reduce, Refine and Recycle). In this concise review, we resume the meniscus anatomical features of the main large animals, to help choose the most suitable animal model for subsequent studies on meniscal repair.

Bone grafiting combined with Sauvé-Kapandji Procedures for the treatment of aseptic distal radius non-union.

Distal radius fractures are the most common type of upper limb fractures in adults. Non-union after distal radius fracture is rare, serious and unpredictable. The aim of our paper is to analyse the clinical and radiological outcomes of bone grafting and Sauvé-Kapandji Procedures for the treatment of aseptic distal radius non-union. We enrolled 13 patients with distal radius aseptic non-union. The following parameters were evaluated: The surgical time, elbow, forearm and wrist range of motion, the subjective quality of life and the wrist function measured by Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Pain Visual Analogic Score (VAS) and the complication rate. Bone union was measured using the radiographic union score as described by Radiographic Union Score (RUS). The evaluation endpoint was set at 24 months after surgery. All patients achieved fracture union. Grip strength improved by 12.4 kg. There was also improvement in wrist flexion, in wrist extension, and forearm pronosupination. These ranges of motion and grip strength improvements were statistically significant. Only 6 patients returned to full activity. This surgical technique represents a reliable alternative for treatment of distal radius aseptic non-unions. Further studies are needed to assess the long-term clinical results of this surgical procedure.

Allograft versus autograft in forearm aseptic non-union treatment.

Non-union in forearm fractures is an uncommon challenging clinical condition for orthopaedic surgeons. The complex anatomy and biomechanics of the upper limb make this surgery very demanding. The accurate restoration of the normal anatomy is mandatory to obtain bone healing. Infections and important bone loss further reduce the therapeutic success. The use of bone graft in atrophic non-union may significantly reduce the bone healing time with good clinical results. The aim of the study was to compare fresh-frozen bone (FFB) allograft and autograft in the treatment of forearm aseptic non-union. Inclusion criteria were patients aged between 18 to 75 years old with forearm aseptic shaft non-union treated with plating and bone grafting. The Authors retrospectively evaluated minimum 12-month follow-up with standard X-rays and clinical outcomes. All non-unions were classified according Association for the Study and Application of the Method of Ilizarov (ASAMI) classification for long bones. The sample size was divided in two groups: patients treated with FFB allograft (Allograft Group) and patients treated with iliac crest autograft (Autograft Group). The mean patient age was 33.58±16.72 (18-75) years old in Allograft Group and 33.28±17.24 (18-75) in Autograft Group. The mean follow-up was 62.6 months (±12.3, range 12-160) in Allograft Group and 64.4 (±12.4; 12-160) in Autograft Group. The mean bone union time after the surgery was 101.6 (±14.6; 82 -156) days in Allograft while 117.6 (±14.6; 90 -180) days for autograft. The Radiographic Union Score was 26.8 (±2.2; range 24.3-30) in Allograft while 26.9 (±2.8; range 24.1-30) in Autograft. A correlation between clinical and radiographic outcomes was found (Cohen κ: 0.86±0.11 in Allograft Group; Cohen κ: 0.85±0.10 in Autograft Group, p=0.051). The preoperative surgical planning is essential to apply this technique: the adequate cortical graft length is the key point to gain adequate implant stability. A meticulous surgical technique is mandatory to obtain good clinical and radiological outcomes. The study reported a good reliability of FFB allograft for large non-union bone defects. This technique may represent a feasible alternative to bone transport or amputation, as it allows the return to daily life activities. Further studies are needed to assess the long-term clinical results of this surgical procedure.

Animal models for cartilage repair.

Cartilage lesions still represent an unsolved problem: despite the efforts of the basic and translational research, the regeneration of this tissue is far from being reached (1-3). Articular cartilage lesions can be divided in two main groups: superficial or partial defects and full-thickness defects (4, 5). Partial lesions are not able to self-heal because multipotent cells from the bone marrow cannot reach the area leading to a progressive degeneration of the tissue (6). Conversely, full-thickness injuries possess greater chances to heal because subchondral bone involvement allows for the migration of mesenchymal cells, which fill the damaged area (7, 8). However, healing occurs through the formation of a fibrocartilaginous tissue, which has different biomechanical and biological properties (9). Native hyaline cartilage has indeed specific biomechanical properties, which confer resistance to compressive and shear stresses; the reparative fibrocartilaginous tissue lacks these abilities, therefore, the surrounding healthy cartilage progressively degenerates. In the past years, several therapeutic strategies have been developed to restore the damaged cartilage, bone marrow stimulation (chondroabrasion, drilling, micro- or nano-fractures) and more recently, tissue engineering approaches (10-14). Some of these latter procedures have already been applied in clinical practice such as matrix-induced autologous chondrocyte implantation (MACI) (15) or osteochondral scaffold implantation (16). Generally, tissue engineering approaches are based on the combination of three main elements: cells (i.e. primary chondrocytes or multipotent mesenchymal cells), biocompatible scaffolds (i.e. polymers, composites, ceramics) and signaling molecules (i.e. growth factors). Moreover, several culture conditions (i.e. static or dynamic cultures) and biomechanical stimuli can be applied during the in vitro culture to promote tissue maturation (17-19). However, an in vivo culture is mandatory to validate a new engineered construct as the in vitro phase lacks the essential in vivo environmental stimuli and because the in vivo culture allows for the testing of the biocompatibility and safety of a new material (18, 19). Moreover, preclinical animal models are crucial to understand the molecular mechanisms of cartilage lesions favoring the development of new regenerative strategies (20, 21). in vivo studies on animal models should focus on the analysis of the cellular component, analyzing the maintenance of the cellular phenotype and the tumorigenicity; on the evaluation of the biocompatibility, toxicity and degradation of the biomaterial and on the assessment of the engineered construct. In this manuscript, we will review the most common preclinical animal models, which are used to understand cartilage biology and therefore to develop new tissue engineering strategies. We will focus on both small and large animal models highlighting their peculiarities, advantages and drawbacks.

External fixation versus titanium endomedullary nail in the treatment of diaphyseal fractures of the lower limb in pediatric age: our experience.

In the past, the use of external fixation technique (FE) in children was limited, as the patient's compliance to the treatment was scarce due to an important visual impact for the little patient. With the evolution of the surgical approach and the technology of fixators, we have been able to considerably implement the treatment possibilities, thus allowing for an immediate load bearing of the operated limb and for the early mobilization of the joints. The FE technique does not represent an overcoming of classical synthesis techniques by internal fixation with elastic intramedullary nails, but it simply offers a valid treatment alternative to selected cases. In this work, we radiologically and clinically evaluated pediatric patients treated with FE for diaphyseal fractures of the lower limb and we compared them with patients treated with standard Titanium Endomedullary Nail (TEN) techniques. Our results confirmed that FE is a valid alternative treatment for these types of fractures.

[Primitive malignant melanoma of the base of the tongue]. / Melanoma maligno primitivo della base lingua.

Although the incidence of malignant cutaneous melanoma has doubled each decade since the early 1960s, the mucous counterpart is still rare, representing 1.4% of all melanomas in caucasian patients. In the oral cavity this incidence is even higher, ranging from 0.2% to 8.0% of all melanomas. However, it is unusual for the primary location to be in the tongue and only 25 such cases have been reported in the literature. In 1974, Conley, reviewing 52 melanomas of the mucous membranes of the head and neck, observed that "it is curious that no melanomas occurred in the tongue". The prognosis for mucosal melanomas is clearly worse than for cutaneous melanoma, with most authors reporting a 5-year survival rate of 10-25%. It is not clear whether mucosal melanomas are biologically more aggressive than their cutaneous counterparts or if prognosis is simply related to the fact that they are normally more advanced at the time of diagnosis. In fact, it is clear that the etiologic and pathogenetic basis for the origin of mucosal melanomas, as well as of their treatment and prognosis, is not understood nearly as well as that of cutaneous melanomas. Historically, cutaneous melanoma has been characterized as radio-resistant, although recent observations regarding the radiobiological and clinical responses have prompted investigators to re-evaluate the role of radiotherapy in localized mucosal melanoma. The authors report a primary malignant melanoma of the tongue base, heavily pigmented, rather bulky and nodular, approximately 0.4 cm in size, very similar to one of the varices usually encountered in this portion of the tongue. The patient came to the authors' observation complaining of peripheral vertigo. The melanoma was suspected due to a pulmonary metastasis observed in a routine chest X-ray and after a thorough search for the possible primary neoplasm. Because of widespread metastases, the patient was not treated with radio or chemotherapy and died 8 weeks after surgical ablation of the primary lesion. As observed by Batsakis, at least 25% of mucosal melanomas are clinically identical to innocent lesions. For this reason, the authors stress the importance of taking into consideration the possibility of mucosal melanoma in the differential diagnosis of head and neck neoplasms and of being suspicious of lesions which appear clinically insignificant.

Injective versus sublingual immunotherapy in Alternaria tenuis allergic patients.

Little knowledge is available on molds either from the environmental or clinical points of view. The latter is mainly due to the lack, until recent times, of purified and standardized extracts. Injective immunotherapy, largely used for patients allergic to mites and pollens, is regarded with some concern for molds. On the other hand, mold-related allergic symptoms (i.e.,from Alternaria tenuis) have in Italy an incidence of about 5 percent, mainly in young patients. We have therefore run a pilot study comparing the efficacy and safety of injective (SIT) and sublingual (SLIT) immunotherapy by administering the same purified and standardized extract of Alternaria tenuis to a total of 23 patients for two years, according to an open experimental plan. Excellent tolerance was shown to SLIT while four (two medium-grade) side effects appeared with SIT. Clinical improvement, subjectively stated comparing symptoms (mainly rhinitis) and drug consumption before and after the therapy, confirmed by an increase in the Specific Nasal Provocation threshold, was obtained with both therapies, but with a statistically significant difference in favour of SLIT. Skin reactivity and blood Alternaria tenuis specific IgE, total IgG and IgG changed in the SIT-treated group, while no statistically significant change was shown in the SLIT-treated group. These results are in good agreement with previous reports on SIT and SLIT with other inhalant allergens (mites, grasses), and suggest the potential use of SLIT for Alternaria allergy, mainly in young patients, when there are concerns about the safety of and compliance with the traditional injective therapy.

Auditory and academic performance of children with unilateral hearing loss.

Since the data provided in the literature concerning unilateral hearing loss in children are still lacking, we decided to study a group of subjects suffering from unilateral sensorineural deafness that has developed during the first 12 years of life. One hundred and fifteen subjects out of 150 answered a questionnaire that intended to investigate at what age the disorder developed, how it was recognized, its possible causes and a subjective evaluation of the difficulties encountered because of the hearing deficiency. In a second stage of the research, more detailed case history data were obtained on 30 children who satisfied more stringent selection criteria. The same children were compared with a matched control group of 30 normal hearing subjects, on speech in noise recognition, and sound localization skills. Results were correlated with the academic and educational progress and case history data. Our results may demonstrate that unilateral deafness represents a far from negligible handicap concerning the child's learning and relationship with classmates and teachers, specially during compulsory school life.

Dichotic performance in elderly Italians with Italian stop consonant-vowel stimuli.

Dichotic listening tests were carried out at various interaural onset asynchronies (from 0 to 500 ms) on normal-hearing young and elderly subjects using a free recall method. The stimuli were Italian stop consonant and vowel syllables computer-edited to reduce prevoicing of the consonant and vowel syllables from the original 100-120 ms to 30 ms. Results suggest that right-ear advantage is uninfluenced by age, despite a significantly lower total dichotic performance and abnormal lag effect in the older group.

Is the auditory brain-stem response (ABR) effective in the assessment of post-traumatic coma?

The aim of the present study is to evaluate the capacity of ABRs to detect the limit between reversible dysfunction and irreversible damage to the brain-stem after severe head injuries. ABRs were recorded in 40 severely head-injured patients, strictly selected on the basis of clinical and CT scan findings and the absence of otologic disease. The interpeak latency of waves V-I (IPL V-I) was calculated and compared to that recorded in 19 healthy control subjects. The distribution curve for IPL V-I in surviving patients was analysed. The overall mortality was 47.5%; all the patients showing an IPL V-I greater than 4.48 msec died or remained vegetative, while all but 2 of the patients with IPL V-I less than 4.48 msec survived. The IPL V-I was significantly different from normal value in surviving patients, showing a brain-stem dysfunction in reversible post-traumatic coma. The 95% confidence limits for the mean IPL V-I in the surviving population were 4.08 and 4.24 msec. Our results confirm the high prognostic accuracy of ABR (P less than 0.001) and suggest the hypothesis that 95% of survivors have an IPL V-I ranging between 3.82 and 4.50 msec.