A prospective study for the treatment of proximal humeral fractures with the Galaxy Fixation System.

BACKGROUND: Fractures of the proximal humerus represent a common problem in clinical practice; in particular for three- or four-part fractures, there is no consensus regarding which is the best treatment. The aim of our study was to report clinical and radiological outcomes in patients treated with the Galaxy Fixation System™ for a proximal humerus fracture. MATERIALS AND METHODS: Thirty-two patients of which 18 (56.25%) women, and 14 (43.75%) men suffering from proximal humerus fractures were treated using the Galaxy Fixation System™. Fractures were classified according to Neer and only patients with a three- or four-part fracture with two-thirds of the methaphysis intact were included. Clinical examination included the Constant-Murley score, UCLA score and Quick DASH evaluated at 6, 12 and 24 months after surgery. In addition, at the final follow-up, patients were asked to complete the SF-12 questionnaire. The humeral head-shaft angle was evaluated by radiographs the day after surgery, as well as after 12 and 24 months. RESULTS: All 32 patients were available for the 6th, 12th and 24th month follow-up examination. The mean interval between trauma and surgery was 2.7 days (range 0-6 days). The period of hospital stay ranged from 2 to 8 days with an average of three days. The time of healing ranged from 4 to 10 weeks with an average of 7 weeks. The mean Constant score increased from 72.9 after 6 months to a mean of 82.8 at 12 months (p < 0.05) to 88.9 at 24 months (p < 0.05). UCLA score ranged from 27.5 at 6 months to 29.5 at 12 months (p < 0.05) and finally improved to 32.3 at final follow-up (p < 0.05). Quick DASH varied from 7.2 at 6 months after surgery to 5.2 at 12 months after surgery (p > 0.05) and reached the value of 3.1 after 24 months (p > 0.05). Mean Mental Component (MCS) resulted in a value of 48.1, while the Physical Component (PCS) was 52.7. The mean head-shaft angulation was 137.6° the day after surgery compared with 137.5° (p > 0.05) measured 12 months later, and 137.2° measured 24 months later (p > 0.05). CONCLUSIONS: Galaxy Fixation System™ is a safe and efficient procedure for the treatment of three- or four-part proximal humerus fractures, providing an excellent outcome. LEVEL OF EVIDENCE: Prospective case series, Level IV.

Early enteral immunonutrition vs. parenteral nutrition in critically ill patients without severe sepsis: a randomized clinical trial.

OBJECTIVES: We compared early parenteral nutrition (PN) and early enteral immunonutrition (iEN) in critically ill patients, distinguishing those with and without severe sepsis or septic shock (SS) on admission to intensive care units (ICUs). DESIGN AND SETTING: Multicenter, randomized, unblinded clinical trial in 33 Italian general ICUs. PATIENTS AND PARTICIPANTS: The study included 326 patients, 287 of whom did not have SS on ICU admission. Eligibility criteria excluded the two tails in the spectrum of critical conditions, i.e., patients either too well or too ill. Of the patients recruited 160 were randomized to iEN (142 without SS) and 166 to PN (145 without SS). INTERVENTIONS: Patients were randomized to two arms: early iEN or early PN. MEASUREMENTS AND RESULTS: Primary endpoint was 28-day mortality for all patients and the occurrence of SS during ICU stay for patients admitted without such condition. While 28-day mortality did not differ between iEN and PN (15.6% vs. 15.1%), patients without SS who received iEN had fewer episodes of severe sepsis or septic shock (4.9% vs. 13.1%). ICU length of stay was 4 days shorter in patients given iEN. CONCLUSIONS: Compared to parenteral nutrition iEN appears to be beneficial in critical patients without severe sepsis or septic shock. Parenteral nutrition in these patients should be abandoned, at least when enteral nutrition can be administered, even at an initial low caloric content.

Platelet-rich plasma supplementation in arthroscopic repair of full-thickness rotator cuff tears: a randomized clinical trial.

BACKGROUND: Results on the effectiveness of PRP supplementation in arthroscopic rotator cuff repair are conflicting, making it difficult to draw definitive conclusions. METHODS: This was a prospective, randomized, and double-blind study with two groups of 20 patients each (PRP group and control group). Degenerative supraspinatus full-thickness tears grade C2-C3 were subjected to arthroscopic repair; PRP supplementation was given to patients in the PRP group. The outcomes were assessed by DASH, Constant scales, and ultrasound before and 6 months after surgery. Pain measured by VAS was evaluated preoperatively and 7 and 30 days after surgery. RESULTS: The two groups did not differ significantly by age, sex, and dominance of the affected side. In all surgical procedures, a long head of the biceps tenotomy and single-row repair were performed. The preoperative VAS was 5.6 ± 2.4 in PRP group and 6.4 ± 1.5 in the control group (p > 0.05). The group supplemented with PRP reported a VAS significantly better in the first week (2.5 ± 1.9 vs 5.3 ± 2.1, p < 0.05) and during the first month after surgery (1.5 ± 1.0 vs 3.2 ± 1.7, p < 0.05) compared to the control group. The preoperative Constant and DASH scores were 39.95 ± 12 and 51 ± 15.2, respectively, in the PRP group and 41 ± 11 (p > 0.05) and 45 ± 12.6 (p > 0.05) in the control group. The average Constant score improved significantly after 6 months to 81 ± 11.2 (p < 0.05) in the PRP group and 78.5 ± 9 (p < 0.05) in the control group. No differences were noted between the two groups (p > 0.05). The DASH score after 6 months was 17.4 ± 8 (p < 0.05) for the treatment group (the PRP group) and 21 ± 8.4 (p < 0.05) for the control group. No statistically significant differences were found as regards the DASH score in the two groups after 6 months (p > 0.05). The two groups showed no differences in the ultrasound evaluation after 6 months either. No re-ruptures occurred in either group. CONCLUSIONS: PRP leads to a reduction in pain during a short-term follow-up. Pain reduction allows for a more rapid recovery of mobilization and improvement in functionality. LEVEL OF EVIDENCE: Randomized controlled trial, Level of evidence, 1.

Tolerability of nimesulide and ketoprofen in paediatric patients with traumatic or surgical fractures.

The anti-inflammatory and analgesic activities of orally administered nimesulide and ketoprofen were assessed in a group of 71 paediatric patients (aged 7 to 14 years) with orthopaedic disorders. Both drugs had similar efficacy. The greatest advantage of nimesulide was its better tolerability: only 3 nimesulide-treated patients (8.6%) experienced side effects related to the drug, compared with 12 (33%) of the ketoprofen-treated children.

Peripheral nerve damage during limb lengthening. Neurophysiology in five cases of bilateral tibial lengthening.

Limb lengthening is used to correct leg length discrepancy and to increase stature. The reported frequency of peripheral nerve complications varies from 5% to 30%, but is probably underestimated. Damage may be direct or be caused by overstretching of the nerves. We have used electrophysiological tests to evaluate five patients during bilateral tibial lengthening by the Ilizarov method. Results after 24 to 107 days of lengthening showed electromyographic evidence of partial muscle denervation in all 10 limbs, with reduced motor conduction velocities in two tibial nerves and three common peroneal nerves. The sensory conduction velocity in the sural nerve was always unchanged. A clear relationship was shown between the amount of tibial lengthening and the degree of electrophysiological abnormality. Our results suggest that subclinical nerve damage is a very frequent complication of tibial lengthening.

Functional assessment of high level ice-dancing.

In these studies the anthropometric characteristics and some functional characteristics of ice-dancers are analysed. It has been shown that the maximum oxygen uptake is similar to that of classical ballet dancers. Tests effected on the ice revealed a high production of lactate, the involvement of the anaerobic metabolism, and high heart rates. It is concluded that the high production of lactate during the free dance on ice is due to the isometric muscular contraction, necessary to maintain certain positions.

[Non-rachitic hypophosphatemic osteopathy]. / Osteopatia ipofosfatemica non rachitica.

We have identified a patient with a condition called Hypophosphatemic Bone Disease (HBD). This disorder of phosphate metabolism is unrecorded by Dent in his final classification of metabolic bone diseases and has been described by Scriver C.R. and coll. Although the condition is in same ways analogous to X-Linked Hyophosphatemia (XLH), there are important differences between the two diseases. For example, there is selective impairment in the tubular reabsorption of phosphate in HBD but the defect is less severe and it is clearly different from that described in XLH. Clinical manifestations of HBD appear in infancy, but the dwarfism and the bone changes are less severe than in XLH at comparable concentrations of plasmatic phosphorus in the two diseases. While in both conditions there is osteomalacia of endostal trabecular bone, only in XLH is florid rickets present, affecting the epiphyses and compromising linear growth. The phosphaturic response to PTH infusion is abnormal in qualitative aspects, but it is present in HBD, and this differs considerably from that described in XLH. The treatment with oral load of phosphates and 1,25(OH)2D3 in every patient with HBD, and so in our patient, is accompanied by increase in serum phosphorus, with improved tubular reabsorption of phosphate anion and a fall of hydrossiprolinuria with bone healing; this combination of responses is not present in XLH.

An integrated approach to safety-driven and ICT-enabled process reengineering: methodological advice and a case study.

Patient safety is a central concern inside any healthcare environment. With the progress of Information and Communication Technologies (ICTs), new solutions have become available to support care and management processes. Analyzing process risks helps identifying areas of improvement and provides ICT-solutions design with indications on what portions of the process need primary interventions. Understanding the link between process reengineering, technology assessment of enabling technologies and risk management allows user acceptance and patient safety improvements. Fondazione IRCCS Istituto Nazionale dei Tumori (INT), offers a good example of process reengineering driven by the purpose of increasing patient safety, enabled by new technologies. A pillar of the evolution of ICT process support at INT is based on Radio Frequency Identification technologies, implemented to identify and trace items and people across processes. This paper will present an integrated approach, based on process reengineering methodologies and risk assessment studies, and methodological advice applied to a case of surgical kits management procedures.

Enterohepatic Helicobacter spp. in colonic biopsies of dogs: molecular, histopathological and immunohistochemical investigations.

Enterohepatic Helicobacter spp. have been described colonizing the large intestine and liver of healthy and symptomatic subjects and are thought to have a role in the development of inflammatory bowel disease (IBD). The prevalence of enterohepatic Helicobacter spp. infection in dogs is largely unknown and to our knowledge there are no data about their potential pathogenic role. In light of these considerations, the aims of this study were (i) to assess the prevalence of enterohepatic Helicobacter spp. in colonic biopsies of symptomatic pet dogs and (ii) to evaluate a possible association between Helicobacter spp. colonization status (heavily colonized, poorly colonized and uncolonized biopsies) and histological lesions. Colonic biopsies from 27 pet dogs of different ages were evaluated by family Helicobacteraceae and enterohepatic Helicobacter spp. PCR, histology, and immunohistochemistry for the in situ detection of Helicobacter spp. organisms. 85% and 52% of colonic biopsies were positive by Helicobacteraceae and enterohepatic Helicobacter spp. PCR, respectively. Immunohistochemistry revealed Helicobacter spp. were localized both in the superficial mucus (55%) and within intestinal crypts (33%). Dogs with heavy enterohepatic Helicobacter spp. colonization were significantly younger and had a higher level of mucosal fibrosis/atrophy than dogs with uncolonized or poorly colonized biopsies (p<0.05). These findings contribute to widen current knowledge regarding canine enterohepatic Helicobacter spp., suggesting the infection is rather common in dogs and acquired at an early age. Furthermore, heavy colonization of colonic crypts is associated with chronic inflammatory lesions (fibrosis/atrophy), supporting the role of enterohepatic Helicobacter spp. in the development of canine IBD.

Partial aplasia of the pectoralis major muscle with an anomalous distal insertion: two case reports.

Two rare cases of subtotal aplasia of the pectoralis major muscle, a residual anomalous formation inserted abnormally into the medial humeral condyle, are discussed.

[Congenital multiple arthrogryposis. Report of a case]. / L'artrogriposi multipla congenita. Contributo casistico.

Six patients affected by arthrogriposis multiplex congenita (AMC) are studied and the detected alterations, the adopted treatment and the obtained results are described and discussed. Notwithstanding the limited number of considered cases, it is underlined that a precocious, constant and protracted treatment can considerably help these patients to gain a certain degree of self-sufficiency though it can not heal serious deformations. This result is also supported by the cases published by the literature.

[Echography of the hip in the newborn. 1507 cases]. / Ecografia dell'anca nell'epoca neonatale. 1507 casi.

The authors report the data relative to 1507 infants studied with clinical and US examination, in the neonatal period, in order to exclude hip dysplasia or dislocation. US examination was carried out according to Graf's technique and the newborns were classified according to US hip type, to clinical examination and to possible risk factors. The patients were included in a protocol including orthopedic and US controls. Seventeen treated infants were considered as pathologic. Ten of them had IIc or D hips at birth; the other 7, with IIa hips at birth, presented a X-ray pathologic hip after the 4th month of life. At about one year of age all infants could normally walk, except for one who was being treated with harness. No statistically significant differences were observed between the number of pathologic infants in the risk group (1.7%) and that in the no-risk group (0.8%). Clinical examination of the newborn has low sensitivity in detecting pathologic hips. On the basis of their results, the authors believe US examination of the newborn to be a valuable screening method to diagnose hip dysplasia/dislocation. Moreover, Graf's morphologic method is the best one for US screening of the hip in the neonatal period.

Congenital pseudarthrosis of the tibia associated with neurofibromatosis-1: treatment with Ilizarov's device.

We reexamined 21 patients with congenital pseudarthrosis of the leg (congenital pseudoarthrosis of the tibia; CPT) associated with neurofibromatosis-1 (NF-1), > or =2 years after the termination of treatment, for a statistical study of the results obtained by using Ilizarov's external fixator. Of the 21 tibias operated on, 17 consolidated after the first treatment, whereas four did not. Of the 17 consolidated tibias, four refractured and were retreated by using a variety of methods. Only one healed. At follow-up, which occurred > or =2 years after the removal of the fixator, the results were nine consolidations without deformities or with shortening <2 cm, five consolidations with axial deviation, and seven nonconsolidations. The statistically significant results were that (a) patients who were aged 5 years or older at operation had better results, and (b) the assembly II (resection of CPT stumps and their short-term compression possibly associated with corticotomy or epiphyseal distraction to correct limb discrepancy) gave better final results compared with the other device assemblies. We conclude that treatment with Ilizarov's fixator allows (a) a good percentage of healing over time (66.7%), especially in cases of normotrophic and cystic CPT; (b) further operations with or without the fixator to correct secondary or residual axial deviation; and (c) correction of limb discrepancy. This treatment avoids risking injury to the healthy contralateral leg. Additionally, for treatments that do not achieve satisfactory results, other treatment methods are not excluded. The CPT still remains a difficult problem for the orthopedic surgeon to solve.

Experimental osteosarcoma in the mouse, induced by Moloney's murine sarcoma virus.

The writers report an experimental trial on the mouse, consisting in the induction of osteosarcoma by inoculation of Moloney's murine sarcoma virus (MSV-M) into the proximal metaphysis of the tibia. This experiment was conducted on 90 BALB/c female mice aged twenty-one days and of mean weight 12.8 g. One group of animals was also given immunodepressive drugs. The tumour developed in 100 per cent of cases, producing metastases in some of the animals and resulting in death in three cases. The radiographic changes were initially osteolytic followed later by new bone formation. The histological examinations confirmed that the tumour was of an osteosarcomatous nature. Cells characteristic of rhabdomyosarcoma were observed in the soft tissues surrounding the bone. The skeletal metastases had the characteristics of osteosarcoma, while those in the lymph glands and lungs had those of an undifferentiated sarcoma. The writers also took into consideration a series of previous trial performed at the Institute of Clinical Orthopaedics of the University of Milan, involving a total of 740 mice, in arriving at their final conclusion that MSV-M induces, in the mouse, an osteosarcoma similar to spontaneous osteosarcoma in man, capable of producing osteoid tissue, of giving rise to metastases, and of causing the death of the animal.

A study of the development of fracture callus in the presence of an experimentally induced osteosarcoma.

The results of two experiments are reported in which the formation of an osteosarcoma was induced in mice by the intraosseous injection of Moloney's virus. In the first group of fifty mice, a complete diaphyseal fracture was carried out nine days later at the site of the tumour. In the second group of 200 mice, a partial fracture was produced at the time of injection so that immobilisation was assured. The effects of cyclophosphamide and calcitonin administration were also studied in this group. The course of the repair processes of the bone was studied in both groups, and showed that, even in the presence of an osteosarcoma, these begin and can reach completion, though obstructed and delayed by the tumour.