Lower-limb intramedullary nailing in patients with polyostotic fibrous dysplasia who had a previous unsuccessful treatment. A report of 48 cases.

BACKGROUND: Intramedullary nailing (IN) seems to be the best primary surgical treatment for patients with either polyostotic fibrous dysplasia or McCune-Albright syndrome (PFD/MAS) when the femur and tibia are totally affected by fibrous dysplasia (FD) and pain, fracture and deformity are likely to occur. However, other management protocols have been applied in these cases, often leading to disabling sequelae. This study sought to evaluate if IN could also have been effective as a salvage procedure to provide patients with satisfactory results, regardless of the poor results due to the improper treatment previously performed. MATERIALS AND METHODS: Twenty-four retrospectively registered PFD/MAS patients with 34 femurs and 14 tibias totally affected by fibrous dysplasia had received various treatments with unsatisfactory results in other institutions. Before the IN performed in our hospital, 3 patients were wheelchair bound; 4 were fractured; 17 limped; and many used an aid for walking. Salvage IN was performed in our hospital at a mean patient age of 23.66 ± 6.06 years (range, 15-37 years). The patients were evaluated before-except for the four fractured ones-and after IN using the validated Jung scoring system, and the data were statistically analyzed. RESULTS: The mean length of follow-up after IN was 9.12 ± 3.68 years (range, 4-17 years). The patients' mean Jung score significantly improved from 2.52 ± 1.74 points before IN to 6.78 ± 2.23 at follow-up (p < 0.05). Ambulation was improved in ambulatory patients and restored in wheelchair users. The complication rate was 21%. CONCLUSIONS: Regardless of the high rate of complications, IN may be considered a reliable surgical procedure to salvage a failed treatment in PFD/MAS, with long-lasting satisfactory results achieved in most patients. Trial registration statement: Not applicable. LEVEL OF EVIDENCE: IV.

Vancouver B2 and B3 periprosthetic femoral fractures treated by ORIF. Mid to long-term follow-up study in 28 patients.

OBJECTIVE: Periprosthetic femoral fractures (PFF) are a serious complication in patients who have undergone hip arthroplasty. Some authors consider revision arthroplasty as the gold standard in the surgical treatment of Vancouver type B2 and B3 PFF. Others, however, prefer treating PFF by open reduction and internal fixation (ORIF), without revising loose stems, especially in elderly patients. In the present retrospective study, we report mid/long-term results in a series of patients affected by B2 or B3 PFF surgically treated by ORIF, using a locking compression plate (LCP), thus avoiding the need of revision arthroplasty. MATERIALS AND METHODS: We reviewed 28 patients affected by B2 or B3 PFF surgically treated between 2010 and 2017 by ORIF using a LCP, after an average follow-up of 5.5 years. The average age of the patients at diagnosis was 78 years; in 17 patients, the femoral stem was uncemented while in 11, cemented. The mean interval time between hip arthroplasty and PFF was 6.7 years. Clinical results were assessed using Harris Hip Score (HHS), while radiographic results according to Beals and Tower criteria. RESULTS: At follow-up, HHS ranged from 72 to 96 points; 8 patients had an excellent result, 12 got a good result and 8 a fair result. According to Beals and Tower criteria, all the radiographic results were excellent (9 patients) or good (19 patients). The majority of our patients returned to their previous ambulatory levels. CONCLUSIONS: According to our results, in elderly patients affected by Vancouver type B2 or B3 PFF, surgical treatment by ORIF using a locking compression plate, without a stem revision, seems to be associated with satisfactory outcome.

Medial subtalar dislocation from a low-energy trauma. A case report and review of the literature.

INTRODUCTION: Subtalar dislocation is a rare injury characterized by a simultaneous dislocation of the talocalcaneal and talonavicular joints. The most common type is caused by high-energy trauma with medial dislocation of the foot. This injury is frequently associated with fractures, but isolated dislocations are also reported. CASE PRESENTATION: We report a rare case of medial subtalar dislocation secondary to low-energy injury in a 61-year-old woman. Following X-rays and CT scan, prompt closed reduction was performed under sedation and, after reduction, X-rays showed a good realignment of the foot. The CT scan revealed an occult non-displaced fracture of the posterior part of the talus. The patient was managed conservatively by a non-weight bearing cast for four weeks, followed by a rehabilitation program. At follow-up, six months later, we observed a good clinical and radiographic result. DISCUSSION: The reported case confirms that the mechanism of injury is an important factor in predicting the final result, since subtalar dislocations secondary to a high-energy trauma are often associated with significant complications. We believe, in agreement with other authors, that a low-energy trauma generally doesn't produce long-term morbidity. Prompt reduction is very important in order to minimize soft tissue and neurovascular complications, although a CT is recommended to identify occult fractures. CONCLUSION: Subtalar dislocations, caused by low energy trauma, if adequately reduced in the emergency room, generally heal with conservative treatment, reducing the risk of significant complications. However, since we report a single patient, further case analysis is needed to make solid conclusions.

Heterotopic ossification around the lesser trochanter of the femur simulating a malignant lesion. A case report with long-term follow-up and revision of literature.

We report the case of a 28-year-old female who complained of groin pain and restricted range of motion of the hip for the previous two months. A plain radiograph, CT scan and MRI of the pelvis showed a bone mass of uncertain origin around the lesser trochanter, simulating malignancy. An open biopsy was performed to obtain a correct diagnosis. The histological examination excluded a malignant lesion. Two months later, the mass was surgically excised and at follow-up, 9 years after surgery, the patient was completely asymptomatic, without any radiographic sign of recurrence. This is a rare case of heterotopic ossification of the proximal part of the femur, that appeared without any significant trauma or other predisposing risk factors; because the lesion led us to suspect a malignant disease, an open biopsy was needed to make the diagnosis. From an accurate review of the literature, heterotopic ossifications mimicking a malignant lesion that appeared without any predisposing factors are extremely rare.

Monitoring of C-reactive protein level (CRP) and Erythrocyte sedimentation rate (ESR) after total hip and knee arthroplasty.

C-reactive protein (CRP) and Erythrocyte sedimentation rate (ESR) are the two most commonly serum biomarkers for the diagnosis of periprosthetic joint infections (PJI). We monitored CRP and ESR in 60 patients affected by osteoarthritis who underwent primary total hip or knee arthroplasty to verify their utility for an early diagnosis of periprosthetic hip and knee infections. In all but two patients, both CRP and ESR increased rapidly after surgery, reaching a peak value around the 3rd day postoperatively; CRP decreased rapidly in 20 days, reaching normal value one month after surgery, while ESR decreased slowly, reaching the normal value after three months. In two patients, CRP and ESR were still elevated six months after the surgical procedure and in both cases a diagnosis of PJI was made. Our study confirms that postoperative screening of CRP and ESR values are very useful in making an early diagnosis of this serious complication.

Orthopaedic aspects in seventy-two children affected by Marfan syndrome. Correlations between pathological features and fibrillin-1 gene mutations.

Marfan syndrome is an autosomal dominant disorder of the connective tissue caused by mutations of the fibrillin-1 gene (FBN1) that primarly involves the cardiovascular, skeletal and ocular systems. We investigated 72 children affected by Marfan syndrome in order to identify possible correlations between some musculoskeletal features and specific mutations of fibrillin-1 gene. The following FBN-1 gene mutations have been observed: a missense mutation in 21 children, a stop mutation in 9, a splice mutation in 15 and other mutations in the remaining 27 patients. We observed a statistical significant association between chest asymmetry and splice mutation (p=0.031) and between scoliosis >20° or thoracolumbar kyphosis and stop mutation (p=0.039). However, we did not find a true genotype-phenotype correlation between the fibrillin-1 gene mutations observed and the prognosis of the disease. Future studies are necessary to demonstrate further genotype-phenotype correlations in order to identify early prognostic markers of Marfan syndrome and to plan the most appropriate clinical management accordingly.

Pubic osteolysis simulating a malignant lesion. A case report with long-term follow-up.

Pubic osteolysis is a rare pathology characterized by a painful radiographic destructive changes in the pubic rami, pubis or pubic symphysis that often follows a post-traumatic event. The etiology is unclear but it is a benign lesion, frequently misinterpreted as malignant. We report a case of a 54-year-old woman with pubic osteolysis mimicking a malignant lesion, diagnosed after open bone biopsy, conservatively treated without any sequelae and followed-up 10 years after the end of treatment. Although in the majority of the reported cases, a previous trauma has been commonly referred, in our case the patient did not refer to any cause before the onset of clinical symptoms. Knowledge of this entity is important to avoid invasive diagnostic procedures, costly investigations or overtreatment.

Use of ceftazidime in the treatment of otorhinolaryngoiatric bacterial infections.

Within the framework of an investigation into otorhinolaryngoiatric bacterial infections in Italy conducted in 1159 patients (607 with otitis media, 354 with pharyngo-tonsillitis and 198 with sinusitis), 124 ceftazidime-treated subjects (92 with otitis media, 22 with pharyngo-tonsillitis and 10 with sinusitis) were observed. The authors report the examination of a number of microbial isolates obtained in the various forms of otorhinolaryngoiatric bacterial infection. Gram-negative organisms were found as causative agents in such diseases, particularly in otitis media. Bacterial resistance to ceftazidime was assessed in all 1159 cases and proved relatively infrequent (3.6%) and markedly less than the detected resistance to other antibiotics (10.7% resistance to cefotaxime, 35% resistance to ampicillin, 43% resistance to penicillin). Ceftazidime, used mainly in otitis media, showed very substantial clinical efficacy with positive results in as many as 97% of cases treated, which is particularly significant, if one considers that roughly 64% of the infections were caused by "difficult" gram-negative bacteria (49% by Pseudomonas).