Bilateral simultaneous hip and knee replacement: an epidemiological nationwide study from 2001 to 2016.

BACKGROUND: Several studies have compared the pros and cons of simultaneous bilateral versus staged bilateral hip and knee replacement but the outcomes of these two surgical options remains a matter of controversy. This study aimed to evaluate demographic features, incidence and hospitalization rates of bilateral one stage total hip and knee arthroplasty in Italy. METHODS: The Italian Ministry of Health's National Hospital Discharge Reports (SDO) were used to gather data. This study referred to the adult population (+ 20 years of age) from 2001 to 2015 for hip arthroplasty and from 2001 to 2016 for knee arthroplasty. RESULTS: Overall, 1,544 bilateral simultaneous hip replacement were carried out. The incidence rate was 0.21 cases per 100,000 adult Italian residents. Male/female ratio was 1.1. The average days of hospital stay was 11.7 ± 11.8 days. The main primary codified diagnosis was: osteoarthrosis, localized, primary, pelvic region and thigh (ICD code: 715.15). 2,851 bilateral simultaneous knee replacement were carried out. The incidence rate was 0.37 cases per 100,000 adult Italian residents. Male/female ratio was 0.6. The average days of hospital stay was 7.7 ± 5.8 days. The main primary codified diagnosis was: osteoarthrosis, localized, primary, lower leg (ICD code: 715.16). CONCLUSIONS: The burden of hip and knee osteoarthrosis as a leading cause of bilateral joint replacement is significant in Italy. The national registers' longitudinal analysis may provide data for establishing international guidelines regarding the appropriate indications for one stage bilateral simultaneous hip or knee replacement versus two stage.

Histological, radiological and clinical analysis of the supraspinatus tendon and muscle in rotator cuff tears.

BACKGROUND: Macroscopic alterations of the affected rotator cuff (RC) are undoubtedly linked to microscopic changes, but they may underestimate the actual degree of the disease. Moreover, it remains unclear whether preoperative structural RC changes may alter clinical outcomes. METHODS: Supraspinatus tendon and muscle samples were collected from 47 patients undergoing RC surgery. Tendons were evaluated histologically according to the Bonar score; fatty infiltration and muscle atrophy were quantified using a software for biomedical image analysis (ImageJ) in percentage of area affected in the observed muscle section. Preoperative shoulder ROM and pain were evaluated. Radiological muscle atrophy was evaluated with the Tangent Sign and Occupation Ratio; fatty infiltration was assessed according to the Goutallier classification. Correlations between histological, radiological and clinical outcomes were assessed. Statistics were performed using the Spearman correlation coefficient. Intraobserver and interobserver agreement was calculated. RESULTS: Histopathologic fatty infiltration (r = 0.007, p = 0.962), muscle atrophy (r = 0.003, p = 0.984) and the total Bonar score (r = 0.157, p = 0.292) were not correlated to preoperative shoulder pain. Muscle atrophy showed a significant but weak negative correlation with the preoperative movement of abduction (r = -0.344, p = 0.018). A significant but weak positive correlation was found between muscle atrophy and the total Bonar score (r = 0.352, p = 0.015). No correlation between histological and radiological evaluation was found for both fatty infiltration (r = 0.099, p = 0.510) and muscle atrophy (Tangent Sign: r = -0.223, p = 0.131; Occupation Ratio: r = -0.148, p = 0.319). Our histological evaluation showed a modal value of 3 (out of 3) for fatty infiltration and an equal modal value of 2 and 3 (out of 3) for muscle atrophy. In contrast, the modal value of the Goutallier score was 1 (out of 4) and 28 patients out of 47 showed a negative Tangent sign. At histology, intraobserver agreement ranged from 0.59 to 0.81 and interobserver agreement from 0.57 to 0.64. On the MRI intraobserver agreement ranged from 0.57 to 0.71 and interobserver agreement ranged from 0.53 to 0.65. CONCLUSIONS: Microscopic muscle atrophy appeared to negatively correlate with the movement of abduction leading to functional impairment. Shoulder pain did not show any relationship with microscopic changes. Radiological evaluation of the supraspinatus muscle alterations seemed to underestimate the degree of the same abnormalities evaluated at histology.

The role of estrogen and progesterone receptors in the rotator cuff disease: a retrospective cohort study.

BACKGROUND: Rotator cuff (RC) tears represent a common cause of shoulder pain and dysfunction in adults. The disease affects primarily women and occurs mainly in the postmenopausal period. This study aimed to investigate immunohistochemically the presence of estrogen receptor-alpha (ER-⍺), estrogen receptor-beta (ER-ß) and progesterone receptor (PR) in the supraspinatus tendon of patients with RC tendinopathy, searching for gender differences of expression. A secondary aim was to evaluate potential links between their expression and the typical histopathological findings of the ailment. METHODS: Biopsies of the supraspinatus tendon were collected intraoperatively from 15 postmenopausal women and 9 men undergoing RC surgery. Specimens were stained with Haematoxylin/Eosin, Masson-Goldner Trichrome, Alcian Blu and immunohistochemical stainings for ER-⍺, ER-ß and PR were performed. Tendon alterations were evaluated with the Bonar histopathological scale. Statistical tests used in this study were the Spearman correlation coefficient and the Mann-Whitney U test. RESULTS: In the supraspinatus tendon, cells expressed ER-⍺ (p = 0.043), ER-ß (p = 0.048) and PR (p = 0.004) with statistically significant differences related to age and sex of patients. Immunoreactivity was seen in the nuclei of tenocytes and vascular cells. Postmenopausal women's samples showed a markedly higher expression of these receptors compared to their male counterpart. There was a positive correlation between the expression of ER-⍺ and ER-ß (r = 0.59; p = 0.02) and between ER-ß and PR (r = 0.72; p = 0.002) in women's samples. Furthermore, in postmenopausal women the PR expression decreased with age (r = - 0.56; p = 0.027). Only in women, the ER-ß expression positively correlated with the total Bonar histopathological score (p = 0.019) and the ER-ß vascular expression positively correlated with ground substance alterations (p = 0.029). CONCLUSIONS: These results reveal that ERs and PR are present in the supraspinatus tendon of patients with RC tears, suggesting a role of sex hormones in the pathogenesis of the disease.

The pathologic basis of recovery.

More patients with end-stage heart failure are now being supported by left ventricular assist devices (LVAD) as a bridge to heart transplant. The LVAD unloads the failing heart and modifies the myocardial structure, with regression of left ventricular hypertrophy. The regression of hypertrophy has been reported histomorphologically in paired samples of myocardial tissues obtained from the same patient at the time of LVAD implantation and the heart excised at transplant. The understanding of the mechanisms of recovery may contribute to strategic development for LVAD weaning and the use of LVAD as a destination therapy.

Epidemiology of Spondylolisthesis: A Nationwide Study From 2001 to 2016 in the Italian Population.

STUDY DESIGN: Epidemiological study. OBJECTIVE: This study aimed to evaluate the annual incidence of spondylolisthesis requiring surgery in Italy and the epidemiological characteristics of the patients. BACKGROUND: The health care system continues to incur considerable costs as a result of low-back pain. Segmental instability of the lumbar spine has attracted significant interest from researchers as a potential mechanism leading to mechanical low back pain. MATERIALS AND METHODS: The Italian Ministry of Health's National Hospital Discharge Reports database in the 2001-2016 period was considered. RESULTS: A total of 55,804 hospital admissions for spondylolisthesis were performed in Italy. The cumulative incidence was 6.8 interventions for every 100,000 Italian adult residents. The highest amount of procedures was recorded in the 65-69 years of age group. The overall patient's age was 56.8 ± 15.1 years. The 62.2% of patients were females. The average hospital stay length was 8.1 ± 7.3 days. On average, older patients require more days of hospital stay. Over the study period, it was observed a decreasing trend in the average number of days of hospital stay. The main primary diagnoses included were "acquired spondylolisthesis" [International Classification of Diseases (ICD) code: 738.4; 57.8%] and "spondylolisthesis" (ICD code: 756.12; 42.2%). By far, the main primary procedure performed was "lumbar and lumbosacral fusion of the anterior column, posterior technique" (ICD code: 81.08; 60.3%). CONCLUSIONS: Spondylolisthesis is a problem in Italy and a leading cause requiring spine surgery. Females were the majority of patients requiring surgery for spondylolisthesis. However, for younger age groups, males showed superior or equal need for spine surgery. The socioeconomic impact of spondylolisthesis in Italy is relevant, affecting patients still in the working population. The increasing trend of spine surgery for spondylolisthesis in Italy may be attributable to the widespread diffusion of modern diagnostic and surgical technologies. LEVEL OF EVIDENCE: Level II.

Colles' Fracture: An Epidemiological Nationwide Study in Italy from 2001 to 2016.

The present study aimed to evaluate the yearly number of Colles' fractures in Italy from 2001 to 2016, based on official information found in hospitalization records. A secondary aim was to estimate the average length of hospitalization for patients with a Colles' fracture. A tertiary aim was to investigate the distribution of the procedures generally performed for Colles' fractures' treatment in Italy. An analysis of the National Hospital Discharge records (SDO) maintained at the Italian Ministry of Health, concerning the 15 years of our study (from 2001 to 2016) was performed. Data are anonymous and include the patient's age, sex, domicile, length of hospital stays (days), primary diagnoses and primary procedures. From 2001 to 2016, 120,932 procedures for Colles' fracture were performed in Italy, which represented an incidence of 14.8 procedures for every 100,000 adult Italian inhabitants. The main number of surgeries was found in the 65-69- and 70-74-year age groups. In the present study, we review the epidemiology of Colles' fractures in the Italian population, the burden of the disease on the national health care system (in terms of length of hospitalization) and the distribution of the main surgical procedures performed for the treatment of the disease.

[Coronary-coronary bypass grafting for myocardial revascularization: a case report].

Off-pump coronary-coronary bypass grafting (CABG) is a main treatment for coronary artery disease and CCBG is one kind of CABG. CCBG is defined as bypass between two segments of the same coronary artery or between different coronary arteries. We present here a case of CCBG using the off-pump technique. The patient had extensive aortic atherosclerosis and both saphenous veins were varicose and therefore only short portions were usable. For some special patients, it is possible to achieve better long-term results and quality of life by CCBG. For surgical approaches, strategy must come before tactics.

Epidemiology of Pediatric Meniscectomy: A Nationwide Study in Italy from 2001 to 2016.

In the pediatric population, meniscectomy should be exceptional. This study aimed to estimate the incidence and trends of hospitalization of pediatric meniscectomy in Italy. Data were collected from the National Hospital Discharge Reports (SDO) reported at the Italian Ministry of Health. This study referred to the pediatric population (0-14 years of age) from 2001 to 2016. A total of 5188 pediatric meniscectomies were performed. The global incidence was 3.9 for every 100,000 Italian residents under 14 years of age. The most frequent age class was 10-14 years. The men/women ratio was 1.1. The average number of days of hospitalization was 1.8 ± 1.4. Men showed more days of hospitalization than women. The 5-9 age group presented the highest length of hospitalization (2.3 ± 1.5 days). The main primary codified diagnoses were as follows: derangement of the posterior horn of the medial meniscus, other derangement of the lateral meniscus, old bucket handle tear of the medial meniscus, and derangement of the lateral meniscus. Primary codified procedures were the excision of semilunar cartilage of the knee and knee arthroscopy. The burden of pediatric meniscectomy is relevant in Italy. The information required to develop global standards for managing pediatric meniscal lesions may be provided by conducting further epidemiological studies.

Left ventricular remodeling, hemodynamics and early clinical outcomes after aortic valve replacement with the Pericarbon Freedom stentless bioprosthesis: results from the Italian Prospective Multicenter Trial.

BACKGROUND AND AIM OF THE STUDY: The aims of this multicenter prospective observational trial were to evaluate: (i) the left ventricular remodeling, hemodynamics and early clinical outcomes of patients undergoing aortic valve replacement (AVR) with the Pericarbon Freedom (PF) stentless bioprosthesis; and (ii) the impact of the two suture techniques--continuous and interrupted--on the hemodynamic performance of the bioprosthesis. METHODS: Between November 2001 and April 2004, a total of 226 patients (131 females, 95 males; mean age 73.2 +/- 8.8 years) underwent AVR with the PF valve (Sorin Group, Saluggia, Italy) at eight Italian cardiac surgery centers. Associated surgery was performed in 73 patients (32%); of these operations, 54 were coronary artery bypass grafting. A continuous-suture technique was used in 132 patients (58%), and an interrupted-suture in 90 (40%). The suture technique was not available for four patients. All patients underwent clinical and echocardiographic evaluation immediately before surgery, and at one, six, and 12 months thereafter. The median follow up was 380 days (Q1: 363 days; Q3: 410 days), and the total cumulative follow up 236.9 patient-years (pt-yr). RESULTS: The overall 30-day mortality was 3.5% (n = 8). Late deaths occurred in 10 patients (4%/pt-yr), of which three were valve-related (1%/pt-yr). The overall and valve-related survivals at one year were 92 +/- 2% and 98 +/- 1%, respectively. Freedom from structural valve deterioration, endocarditis, reoperation and thromboembolic events was 100%, 93 +/- 1%, 98 +/- 1% and 99 +/- 1% at one year, respectively. The peak and mean transprosthetic gradients at one year were: 19.7 +/- 12.27 and 8.7 +/- 6.0 mmHg, respectively. After 12 months, significant reductions (compared to preoperative) were observed in the left ventricular mass (148.5 +/- 48.8 versus 194.4 +/- 54.6 g/m2; p < 0.001) and mean wall thickness (1.08 +/- 0.19 versus 1.32 +/- 0.23 cm; p < 0.001). The continuous-suture technique showed a trend towards lower postoperative gradients than did the interrupted-suture technique. CONCLUSION: The data obtained indicated that the PF bioprosthesis provided excellent results in terms of left ventricular mass regression, hemodynamics, and early clinical outcome. Although a trend towards a better hemodynamic performance of the continuous-suture technique was observed, this aspect requires further evaluation.

Methylphenidate Alters Functional Connectivity of Default Mode Network in Drug-Naive Male Adults With ADHD.

Objective: This study evaluated the hypothesis that methylphenidate immediate release (MPH-IR) treatment would improve Default Mode Network (DMN) within-connectivity. Method: Resting-state functional connectivity of the main nodes of DMN was evaluated in a highly homogeneous sample of 18 drug-naive male adult participants with ADHD. Results: Comparing resting-state functional connectivity functional magnetic resonance imaging (R-fMRI) scans before and after MPH treatment focusing exclusively on within-DMN connectivity, we evidenced the strengthening of functional connectivity between two nodes of the DMN: posterior cingulate cortex (PCC) and left lateral parietal cortex (LLP). Conclusion: Our results contribute to the further understanding on how MPH affects functional connectivity within DMN of male adults with ADHD and corroborate the hypothesis of ADHD being a delayed neurodevelopmental disorder.

Mitral Valve Replacement With a Third-Generation Porcine Valve: An Italian Multicentered Study.

BACKGROUND: Postoperative outcomes of a third-generation porcine bioprosthesis for mitral valve replacement (MVR) have been poorly addressed. The objective of this study was to perform an independent, retrospective, multicenter study on outcomes of patients undergoing MVR with a Mosaic (Medtronic Inc, Minneapolis, MN) porcine bioprosthesis. METHODS: From 1998 to 2011, 805 patients underwent MVR with a Mosaic porcine valve in 11 cardiac centers. There were 465 female patients (58%), and the overall mean age was 73.5 ± 7 years. Associated procedures included coronary artery bypass grafting (201 patients; 24.9%), aortic valve replacement (152 patients; 18.9%), tricuspid annuloplasty (187 patients; 22.3%), and other cardiac procedures (116 patients; 14.4%). RESULTS: Median follow-up was 44 months (interquartile range, 16 to 63), with a cumulative duration of 2.769 patient-years. Early mortality for isolated elective MVR was 3.8% (12 of 313), and overall early mortality was 7.8% (n = 63). The rate of late mortality was 3.4%/patient-year (95 late deaths). At 10 years, overall survival was 57.4% (95% confidence interval [CI], 48.8% to 67.5%), and cumulative rates of cardiac- and valve-related death were 7.4% (95% CI, 4.8% to 10.1%) and 1.1% (95% CI, 0.2% to 1.9%), respectively. The 10-year cumulative rates of thromboembolic and hemorrhagic events were 6.6% (95% CI, 1.4% to 11.8%) and 3.9% (95% CI, 0.1% to 8%), respectively, and the 10-year cumulative incidence of prosthetic valve endocarditis was 3% (95% CI, 1.2% to 4.9%). Finally, the 10-year cumulative incidences of structural valve degeneration and reoperations were 5.8% (95% CI, 0.2% to 11.5%) and 4.8% (95% CI, 0.7% to 10.3%), respectively. CONCLUSIONS: This independent, multicenter, retrospective study indicated that the Mosaic porcine bioprosthesis for MVR provides satisfactory results in terms of both early and long-term outcomes up to 14 years from its implantation.

Cardiac hemangioma of the left atrial appendag: a case report and discussion.

Cardiac hemangioma is an extremely rare, benign vascular tumor of the heart. In contrast to myxoma, hemangioma rarely involves left atrial tissue in adults and little information about the tumor is available. We encountered a 65-year-old woman with a left atrial hemangioma arising in the appendage and growing like an extracardiac mass. The tumor was removed from the left atrium with all the left appendage under cardiopulmonary bypass. Histopathological examination revealed that it was a cavernous-type hemangioma. Among the five described cases, this case was the only one in which the tumor arose from the appendage and grew into the pericardial cavity with resultant paroxystic atrial fibrillation.

Early and long-term outcome of mitral valve repair with a Cosgrove band combined with coronary revascularization in patients with ischemic cardiomyopathy and moderate-severe mitral regurgitation.

BACKGROUND AND AIM OF THE STUDY: Clinical and echocardiographic results were investigated to evaluate mitral valve repair in patients undergoing coronary artery bypass grafting (CABG) for ischemic cardiomyopathy (ICM) with moderately severe mitral regurgitation (MR). METHODS: A total of 78 patients (21 women, 57 men; mean age 69.5 +/- 7.8 years) with ischemic mitral regurgitation underwent mitral valve repair and CABG. The mean left ventricular ejection fraction (LVEF) was 42.4 +/- 12.4%. Among the patients, 19 (24.4%) had preoperative congestive heart failure (CHF). This surgery constituted a second such operation in five patients (6.4%). The MR was grade 3+ in 28 patients (35.9%) and 4+ in 50 (64.1%). The mean number of grafts was 3.6 per patient. RESULTS: Hospital mortality was 11.5% (n = 9). Risk factors for early mortality were preoperative NYHA class > or = III (p = 0.014), preoperative heart failure (p <0.001) and reoperation (p = 0.002). The five-year survival was 82.6 +/- 5.9%, and freedom from grade > or =2+ MR was 93.1 +/- 4.1%. Postoperatively, 66 patients (89.6%) were in NYHA class I and seven (9.4%) in class II, demonstrating a statistically significant improvement (p = 0.03). Late echocardiography showed a significant improvement in LVEF (from 42.4 +/- 12.4% to 51.7 +/- 10.9%; p = 0.01) and a reduction in pulmonary artery pressure (from 37.6 +/- 11.9 mmHg to 29.3 +/- 7.4 mmHg; p = 0.004). CONCLUSION: It is concluded that in patients with ICM, mitral valve repair combined with CABG provides a dramatic improvement in ejection fraction and in CHF, with excellent long-term survival, even in patients with a low LVEF.

Modified Coronary Reimplantation for Small Aortic Root Replacement Mismatch.

Coronary reimplantation is a key step of aortic root replacement and may present special challenges under specific circumstances. Particularly in reoperations, mobilization of the coronary ostia can be hazardous and reattachment may require one or more interposition grafts to avoid tension, as originally described by Cabrol. We report a modified reimplantation technique of the coronary arteries that allows the creation of wide neo-ostia with minimal prosthetic material in case of a small aortic root.

Human dilated ascending aorta: Mechanical characterization via uniaxial tensile tests.

Aneurysms of the ascending aorta (AsAA), i.e., a progressive and localized dilatation of the first part of the aorta, represent a severe life-threatening condition, often occurring with no symptom. AsAA formation is associated with a degeneration of the aortic wall tissue, which leads to changes in the tissue mechanical properties, and in particular to increased wall stress and/or decreased wall ultimate strength. Nowadays, the decision to surgically operate is usually based on the AsAA diameter, although such a criterion is not always predictive. The present study focuses on the mechanical characterization of the AsAA tissues. Specimens were cut from portions of dilated ascending aorta excised from 46 patients through open-heart surgery. Peak strain, peak stress, and maximum elastic modulus (i.e., tissue stiffness) were measured from uniaxial stress-strain curves. Such (ultimate) mechanical properties were collected for different regions of the aortic wall (anterior and posterior) as well as for different specimen orientations (circumferential and longitudinal). Relationships of ultimate mechanical properties with patient age and sex were also investigated. The obtained results highlighted a significant anisotropy of the AsAA tissue (as also observed for healthy aortic tissues), with higher value of strength and stiffness in the circumferential than in the longitudinal direction. Higher strength and stiffness were also found in the posterior region with respect to the anterior one for the circumferential orientation, whereas an opposite result was found for the longitudinal orientation. A decreasing trend of ultimate mechanical properties with aging was also highlighted. Finally, a significant difference in the strength between male and female was observed only in the circumferential direction.

A simple method to adapt the height of the sinotubular junction of the De Paulis Valsalva graft to the height of the patient's sinuses in David reimplantation procedure.

De Paulis and associated introduced a new aortic root conduit for valve-sparing operation. The use of this prosthesis for David I (reimplantation) procedure occasionally may be problematic when the top of the commissures, do not match the new sinotubular junction of the graft. We propose a simple method that allows to create a new sinotubular junction at the desired level in the skirt portion of the Valsalva prosthesis.

Shaping a vascular graft for total aortic arch replacement.

Aortic arch replacement extended to the ascending and/or descending thoracic aorta with a single vascular graft may cause kinking of the prosthesis. We propose an artifact to obtain a curved prosthesis from a straight one for total aortic arch replacement without the risk of kinking.

Effective method to control catastrophic hemorrhage during redo sternotomy.

Redo sternotomy is a challenging surgical procedure performed with increasing frequency; catastrophic hemorrhage is a rare but highly lethal complication. We report our experience in treating this complication in 3 cases of 307 reoperations and propose a simple method to control catastrophic hemorrhage during sternal reentry.

Aortic perforation due to cardiac resynchronisation therapy defibrillator lead placement: Case report and medicolegal considerations.

A 45-year-old woman with dilated cardiomyopathy was admitted for the upgrade of a previously implanted pacemaker. Echocardiography showed intraventricular dyssynchrony and a low ejection fraction (0.35). Treatment with a cardiac resynchronization therapy defibrillator (CRT-D) was selected and the device was implanted. CRT-D interrogation revealed proper function. Following procedure termination, the patient went into cardiac arrest and died despite resuscitation attempts. An autopsy revealed that the medial aspect of the right atrium was pierced by an active lead and that the aorta had a deep lesion, 2 mm in length, on its lateral aspect. We explain the probable pathogenesis of this patient׳s death.

Antegrade cerebral perfusion by axillary artery and left carotid artery inflow at moderate hypothermia.

Cerebral protection during hypothermic circulatory arrest was obtained by combining right carotid perfusion through the axillary artery with selective perfusion of the left common carotid artery in ten patients. We believe that the proposed technique offers several advantages. (1) The axillary artery is generally free from atherosclerosis. (2) It eliminates the risk of retrograde embolization. (3) It provides antegrade perfusion of the true lumen in aortic dissection. (4) Antegrade cerebral perfusion is never interrupted. (5) Bihemispheric perfusion is assured. (6) The risk of air embolysm during carotid cannulation is reduced.