Clinical evaluation of sodium hyaluronate in the treatment of patients with sopraspinatus tendinosis under echographic guide: experimental study of periarticular injections.

PURPOSE: The purpose of this study was to examine the effect of periarticular injection of hyaluronate into shoulders with supraspinatus tendinosis under echographic guide. METHODS AND MATERIALS: The subjects were 56 patients with clinical, echographic and magnetic resonance diagnosis of supraspinatus tendinosis. They were divided in two groups by random sampling; 28 patients were assigned in SH group (sodium hyaluronate) and 28 patients in SC group (sodium chloride). The test drug was 20mg sodium hyaluronate (2ml, Hyalgan, Fidia SpA, Abano T., P.M. 500-700.000, 20mg/2ml). RESULTS: Preliminary results showed that sodium hyaluronate presented the highest efficacy in the improvement of clinical symptoms and recovery of functional status in patients with supraspinatus tendinosis in fact the mean V.A.S. score (Visual Analogue Scale) at 1 month after the end of the infiltrative cycle was 8.0 in the SC group vs. 2.8 in SH group and these numerical data were substantially unchanged also after 3 and 4 months. CONCLUSION: Hyaluronate injection under echographic guide should be use not only as a lubricant but also to prevent articular cartilage degeneration and cover and protect the articular cartilage; indeed sodium hyaluronate can decrease inflammatory joint process.

Cauda equina syndrome secondary to idiopathic spinal epidural lipomatosis.

STUDY DESIGN: Three cases of idiopathic epidural lipomatosis are reported. OBJECTIVES: Description of the relationship between spinal pathologic overgrowth of fat tissue and neurologic symptoms. SUMMARY OF BACKGROUND DATA: Idiopathic epidural lipomatosis is a very rare condition; it is usually secondary to chronic steroid therapy or endocrinopathic diseases. METHODS: Three men with a mean age of 58.5 years, who experienced intermittent claudication, bilateral radicular pain in both legs, and urinary dysfunction with hypoesthesia in the perineal region, were evaluated by plain radiography and magnetic resonance imaging, the results of which demonstrated a pathologic overgrowth of fat tissue in the spinal canal with a marked impingement of the dural sac. Obesity, endocrinopathic diseases, and chronic steroid therapy were excluded for all patients. Surgical treatment was performed by wide multilevel laminectomies, fat debulking, and instrumented posterolateral fusion. RESULTS: After surgery there was a gradual improvement in symptoms and signs so that 2 years later the patients returned to daily activities and were neurologically normal. CONCLUSIONS: Spinal epidural lipomatosis can be a cause of back pain but rarely radicular impingement. Magnetic resonance imaging is the procedure of choice. The treatment must be performed early by wide surgical decompression.

The surgical treatment of spondylolisthesis with transpedicular stabilization: a review of 25 cases.

The present study concerns a series of 25 patients submitted to vertebral stabilization and fusion for the treatment of spondylolisthesis. In all of the cases a transpedicular screw system was used. The Steffee plates and screws system was used in 22 cases; the Cotrel-Dubousset (CD) system was used in 3. The listhetic vertebra was L5 in 14 cases, it was L4 in 11 cases. Based on Meyerding radiographic criteria there were: grade I: 8 cases, grade II: 13 cases, grade III: 4 cases. Instrumented fusion was performed at only 1 level in 20 cases, at 2 levels in 5 cases. Mean follow-up was 29 months. Clinical results were evaluated based on the White criteria. The results were satisfactory in 78% of cases. The present study shows that transpedicular vertebral stabilization constitutes a safe method, offering excellent stability essential to consolidation of fusion.

[Diagnostic problems in Ewing's sarcoma]. / Problematica diagnostica del sarcoma di Ewing.

Ewing's sarcoma presents diagnostic problems with several inflammatory processes (osteomyelitis, osteoperiostitis, eosinophilic granuloma) and other bone tumors. Clinical, radiographic and laboratory findings must be supported by a careful biopsy. Delimitation of reticulosarcoma and metastatic neuroblastoma is also extremely difficult from a histopathological point of view.

[Intradural herniated disk: report of 2 cases]. / Ernia del disco intradurale: descrizione di due casi.

Taking advantage of the observation of 2 instances of intradural disk herniation, the authors examine the pathogenetic, clinical, diagnostic, and therapeutic aspects of this rare occurrence in light of a review of the literature and their own observations. Of the theories as to the cause of the syndrome, two appear worth noting: the relative immobility of the dural sac, bound by the surrounding nerve roots; the inflammatory and cicatricial adhesions that establish themselves between the posterior longitudinal ligament and the dural sac. The clinical features as well as the laboratory and diagnostic tests suggest compression of one or more nerve roots similar to that caused by other intradural expansion processes. The onset can be sudden and acute or delayed depending on whether the dural sac adhesions were present before disk herniation or appeared at a later stage. Intradural disk herniation must be checked for, often intraoperatively, in all cases of radiculopathy due to intradural compression. Error in the assessment of the level of the lesion, concomitant extruded extradural disk herniation, or failure to recognize the immobility of the dural sac can all lead to misdiagnosis of intradural disk herniation if the search for this syndrome is not correctly carried out.

[Reticulosarcoma: diagnostic problems]. / Reticolosarcoma: problematica diagnostica.

Diagnostic problems connected with reticulum cell sarcoma are analyzed. Clinical, radiological, biochemical and hematological investigations combined with an accurate pathologic study are essential in order to arrive at a precise diagnosis. Ewing's sarcoma and other osteolytic sarcomas are discussed in the differential diagnosis.

[The modality of endoconnective ossification on cartilaginous substrate: observations on the long bones in the embryo]. / Modalità di ossificazione endoconnettivale su substrato cartilagineo: osservazioni sulle ossa lunghe dell'embrione.

The authors conducted a histologic study on the modalities of ossification of the "diaphyseal osseous ferrule" in embryos between the sixth and eighth week of intrauterine life: the ossification of this "diaphyseal osseous ferrule" presents some peculiarities compared to that of other areas: it occurs with the modalities of periosteal ossification, exploiting, however, a cartilagenous substrate. In addition, the authors compared the ossification of the diaphyseal ferrule to that of the "perichondrial ferrule of the layer of ossification", examining histologic sections of embryos in the 25th week of intrauterine life.

[Perichondrial changes in the evolutionary course of traumatic lesions of the epiphysis in growth]. / Modificazioni del pericondrio nel corso evolutivo di lesioni traumatiche di epifisi in accrescimento.

The authors conducted an experimental study aimed at defining the response of the perichondrium to traumatic stimuli. Thirty rabbits were used, subdivided into two groups: in the first group, the perichondrium was submitted to indirect trauma (fracture of the growth nucleus); in the other, to direct trauma (decortication of th perichondrium). We observed that the lesions constitute a stimulus for cellular proliferation with successive differentiation depending on various procedures. The mesenchymal cells of the deeper layer of the perichondrium reveal a tendency towards differentiation in a chondroblastic sense; the portion of these cells which face the metaphysis are generally differentiated to constitute typical cytotypes of the periosteum, giving way to membranous ossification phenomena. The more external layer reveals proliferation of its fibrovascular component. This experimental model allowed us to emphasise the proliferative tendency of so-called perichondrial cells (those of the deep layer). Thus, their role in providing the growth cartilage of new chondrocytes was confirmed, contributing to the transverse development of the metaphysis.

Experimental investigation into reparative osteogenesis with fibrin adhesive.

An experimental investigation was carried out in order to evaluate the effects of fibrin adhesive on the reparative osteogenesis of bone grafts in the short, medium, and long term. Sixty fully developed New Zealand White rabbits under general anesthesia were grafted with homologous bone tissue in the proximal third of each tibias. Fibrin adhesive was used in one hind limb only. The animals were killed at a predetermined time. Both tibias were removed and subjected to radiographic and histologic analyses. The reparative process was observed and the differences between the fibrin adhesive-treated grafts and the reference group in the first few weeks were determined. No substantial difference was detected in the reparative osteogenetic process of the graft in the animals killed after 2 months.

[Chordoma (a review of 11 cases)]. / Cordoma (rassegna di 11 casi).

Eleven cases of chordoma, localized at sacrum (3 cases), lumbar spine (6 cases), cervical spine (2 cases), are reported. Authors describe clinical and pathological findings of the tumor and underline peculiarity of spinal localization and difficulty of diagnosis, often delayed, particularly in sacral spine localizations. Radiotherapy and chemotherapy give poor results while surgery can be employed in the treatment on account of the slow evolution and of the not very frequent aptitude of the tumor to give metastases. However peculiar localization into the sacral spine allows to remove the whole tumor if only it is localized below the 2nd sacral vertebra; authors present such a case treated by means of subtotal resection of sacrum and coccyx. In proximal sacral localizations and in other spinal localizations, surgery is a palliative procedure and can only slow down the evolution of the tumor; recurrence is a rule, even in association with radiotherapy. However surgical treatment must be often performed because of myeloradicular involvement.

[The role of osteotomy in the therapy of the arthritic genu varum]. / Il ruolo della osteotomia nella terapia del ginocchio varo artrosico.

The good results achieved with osteotomy in the treatment of arthritic varus knee lead the authors to pinpoint some frequently controversial aspects that are important for the attainment of an excellent outcome. The study consisted of 46 patients, each subjected to valgus osteotomy. The site of the tibial osteotomy should be above the insertion point of the patellar tendon in order to better guarantee stability and healing. For mechanical reasons, high metaphyseal peroneal osteotomy is preferred over other methods such as diaphyseal osteotomy, excision of the peroneal head, and proximal tibioperoneal syndesmotomy. Both osteotomies can be done through a single anterolateral incision, without risking injury to the lateral popliteal sciatic nerve. The preferred method of osteotomy is to cut a noncuneiform linear rima with the osteotome and perform the angular correction at the joint of the metaphyseal spongy bone. The osteotomy is then stabilized with staples and a cast for a period of 40 days. Overcorrection past the physiological valgus deformity is necessary in order to move the weight-bearing axis onto the lateral hemirima; the degree of surgical correction should be calculated on the basis of orthostatic radiographs. Good clinical results are always accompanied by the following radiographic developments: opening of the medial articular hemirima, improvement of the subchondral bone sclerosis, and reappearance of the outlines of both the spongy bone and the subchondral bone lamina; all these are signs of good bone adjustment made possible by the reinstatement of mechanical equilibrium in the knee.

[Percutaneous nucleotomy: the indications and limits]. / La nucleotomia percutanea. Indicazioni e limiti.

The authors report the results of automated percutaneous diskectomy in the treatment of the herniated disk. During an 18-month period this procedure was used on 39 patients with both evident radicular pathology that had not regressed even after 4-6 weeks of medical and physical therapy as well as clear disk herniation revealed by diagnostic imaging. The level of the herniated disk was L4-L5 in 30 cases. L5-S1 in 7 cases, and L3-L4 in 2 cases. The clinical diagnosis was confirmed by CAT scan in 20 cases, by both CAT scan and x-ray of the spinal region in 14 cases, and by x-ray only in 5 cases. The patients were reviewed 2, 6, and 12 months after surgery. The results were classified according to Watters' criteria based on both the relief of pain and the resumption of everyday work activity. The satisfactory results (excellent and good) totaled 59% at the 6-month follow-up, with no substantial variation at the 1-year follow-up. Hemilaminectomy was performed in 12 cases with unsatisfactory results, confirming the diagnosis of disk herniation in 10 cases (extruded in 9 cases and protruded in 1 case). Diskectomy is a non-invasive, atraumatic method which is indicated for both protruded (non-sequestrated) and subumbilical hernias and allows rapid functional recovery. The rate of success can be increased with more accurate selection of patients based on imaging diagnosis (CAT scan and MRI).

[The action of loads on bone tissue]. / L'azione dei carichi sul tessuto osseo.

This paper analyses the effect of mechanical loading on bone remodelling under both physiological and pathological conditions. The sensitivity and the type of the biological response of bone to the changes in mechanical loading are conditioned by several factors: individual race and age, pattern of stress, systemic and local metabolic conditions, etc. Therefore, bone remodelling following mechanical stress is not only a simple repair process, but a complex mechanism of functional adaptation which is controlled by the strain magnitude of bone structure rather than the extent of the stress. Results show that the skeletal changes induced by mechanical stress involve not only the structural properties but also the material characteristics of bone. For example, the size of hydroxyapatite crystals increases under load. These findings allow us to hypothesize that mechanical stress could directly modify the mineral component of bone. Hydroxyapatite appears to be a highly dynamic structure, able to change its crystallinity in relation to external stimuli. It is thus conceivable that hydroxyapatite crystals gather and arient themselves along bone and improve their crystallinity not only under the influence of biological mechanisms, but also as a reaction to mechanical stimuli.

Soft tissue trauma: a randomised controlled trial of the topical application of felbinac, a new NSAID.

Two hundred and thirty-one patients with acute soft tissue injuries were treated in a double-blind placebo-controlled study of felbinac (biphenylacetic acid) gel applied three times daily to the injured site. Those treated with felbinac had significantly greater improvement at Day 4 (p less than 0.001) and Day 7 (p less than 0.02) than those who received placebo. Patients' self-assessment diary cards confirmed superiority of the active treatment as early as Day 2 of the study. Local skin reactions were few (three per cent), mild and recovered spontaneously. Felbinac is an effective management for acute soft tissue injuries and because of its topical application may be safer than oral non-steroidal anti-inflammatory drugs for the treatment of these conditions.

Scanning electron microscopy study of articular cartilage in the evolution of hip arthritis.

The authors report the results of scanning electron microscopy examination of samples of articular surface taken from 15 arthritic femoral heads removed during hip replacement. The specimens were collected from areas of the femoral head where different degrees of degenerative changes were identified, and processed with the normal techniques for scanning electron microscopy. A definition was made of the mechanisms leading to articular cartilage wear, the most obvious sign of cartilage degeneration. The earlier stages were characterized by the appearance of clefts in the surface layer, which merged and formed scales that flaked off, giving rise to superficial abrasions. The evolution of the degenerative process led to a deepening of the clefts, reaching the intermediate and deep layers and creating further scales of cartilage tissue, oblique or perpendicular to the surface. The elimination of these formations causes more or less marked wear that can extend down to the subchondral bone (ulcers and ground surfaces). As well as information on the condition of the articular surfaces, scanning electron microscopy may also provide details on the morphology and structure of the chondrocytes and the fibrillar network in the sagittal sections, showing the regressive phenomena associated with arthritis.