Is antegrade nailing a proper option in 2- and 3-part proximal humeral fractures?

PURPOSE: To report our experience with antegrade short locked intramedullary nail for treatment of proximal humeral fractures and to review the current literature. MATERIALS AND METHODS: From January 2012 to July 2013, 41 patients affected by two and three-part proximal humeral fractures were treated with surgical internal fixation with short locked intramedullary nails. Outcome analysis included standard clinical follow-up, Constant shoulder score and plain radiographs. The mean follow-up was 30 months (range 24-42). Moreover, a review of the literature was carried out. RESULTS: The mean Constant shoulder score was 81.5, excellent functional outcomes in 24/38 patients. All the fractures healed in an average time of 3.7 months. Five patients underwent additional operations, complications included hardware penetration into the joint (n = 2), backed out screw (n = 1), shoulder impingement due to protrusion of the nail (n = 2) and superficial infection (n = 1). The literature review showed 530 patients affected by proximal humeral fracture and treated with intramedullary nail with mean age of 65 years, mean follow-up of 22.2 months and a Constant shoulder score of 72.9 points; the major complications reported were backing out of the screws, shoulder impingement and joint protrusion of the screws. CONCLUSIONS: Antegrade short locked intramedullary nail allows stable fixation, minimal soft tissue dissection, early mobilization of the shoulder and good outcomes. It is an efficacious therapeutic solution for 2- and 3-part proximal humeral fractures.

[Aneurysms of the celiac artery: case report and review of the literature]. / L'anévrysme de l'artère coeliaque.

Aneurysm of the celiac trunk is uncommun, accounting for 6% of all splanchnic artery aneurysms. Atherosclerosis is the main cause, other causes include fibrodysplasia and more rarely mycotic or post-stenotic conditions. Usually asymptomatic, detection is generally fortuitous. Ultrasound, angiography and CT scan provide the positive diagnosis. Rupture is the most serious complication. The risk is about 13% per year with high mortality (80%). Cure can be achieved by conventional or endovascular surgery. We report an aneurysm of the bifurcation of the celiac trunk in a 70-year-old woman. Diagnosis was fortuitous. The aneurysm was sacciform with a 2.5 cm diameter and a large collar. Because of its locations and shape, no endovascular procedure could be attemped. Reconstruction with a patch was achieved with conventional surgery. The post-operative period was uneventful. Ultrasound at 3, 6, 12 and 36 months showed a normal caliber with regular blood flow in the reconstructed vessels.

[Popliteal vein aneurysms]. / Les anévrysmes de la veine poplitée.

We report our experience with four cases of popliteal vein aneurysms treated over the last five years. The pathogenesis of these rare lesions is unknown. The inner wall of true venous aneurysms exhibit a reduced number of muscle fibers and fragmented elastic fibers replaced by fibrous tissue. The most dangerous risk related to popliteal vein aneurysm is pulmonary embolism. Diagnosis is based on phlebography and duplex Doppler findings. Surgery can provide cure and prevent complications. We treated our four patients with an asymptomatic aneurysm of the popliteal vein with aneurysmectomy using an atraumatic clamp and direct suture. Oral anticoagulants were given and elastic compression was maintained for six months, with satisfactory results.

[Renal artery aneurysms. Our experience]. / Les anévrismes de l'artère rénale. Notre expérience.

A retrospective study concerned 8 aneurysms of the renal artery. There were 6 females and 2 males with a mean age of 50.7 years. Diagnosis was obtained angiographically in all cases, in 7 during a reno-vascular work-up for hypertension and fortuitously in 1 after angiography for arteriopathy of the lower limbs. The aneurysm was due to fibromuscular dysplasia in 5 cases and to atheromatous lesions in 3. Reconstruction techniques and their indications were analyzed on the basis of a review of the literature. Outcome for hypertensive patients are the same for the different techniques.

[Temperature monitoring and sites of measurement of body temperature]. / Monitoraggio termometrico e siti di rilevamento della temperatura corporea.

The authors report an investigation of 331 consecutive patients submitted to major surgery to evaluate the reliability of temperature monitoring in different body sites in relation to central temperature. After having considered the minimal temperature changes and the difficulties due to the different techniques used, it is concluded that the measurement at the middle 3rd of the oesophagus is the most reasonable measurements site.

[The propofol-fentanyl-pancuronium combination in aorto-coronary bypass. Experience and personal caseload]. / L'associazione propofol-fentanyl-pancuronio nei by-pass aorto-coronarici. Esperienza e casistica personali.

The authors report the use of a total intravenous anaesthesia in CABG. An association of propofol-fentanyl-pancuronium with a bolus at induction, then with continuous perfusion was used. Hemodynamic and oxymetric data obtained from the right heart and radial artery samples show good hemodynamic stability during surgery. It is underlined that, in order to reduce possible hemodynamic changes it is very important to use, during the surgical procedure, the lowest drug concentration.

[Reducing bleeding during extracorporeal circulation interventions by high doses of aprotinin]. / Riduzione del sanguinamento negli interventi in circolazione extracorporea mediante l'uso di alte dosi di aprotinina.

The great risk of severe infectious diseases transmission through blood transfusion, has increased during the last years the effort to reduce the bank blood and its derivates use. Many techniques have proposed to achieve this purpose during and post cardiopulmonary bypass: normovolemic hemodilution, perioperative blood autotransfusion, postoperative return of extra corporeal circuit and chest drains blood and the particular use of some drugs. In the last few years several reports have been presented in the literature concerning the reduction of intra and postoperative bleeding in cardiac surgery by high dose Aprotinin administration. A randomized study with the use of this pharmacologic agent is presented: a group of patients was treated with Aprotinin (shared in two subgroups receiving respectively a different dose of the drug) and a control group. The results were highly encouraging both because of the reduction of peri and postoperative bleeding and because of the bank blood use important reduction.

[Botallo's duct with pulmonary hypertension in the adult]. / Il dotto di Botallo con ipertensione polmonare nell'adulto.

A patent ductus arteriosus in adults is a rare eventuality. After correct diagnosis, an accurate evaluation of pulmonary vascular resistances is necessary with, in case of normality, a straightforward indication to surgery, because the evolution of the disease cannot be predicted. In case of pulmonary hypertension irreversible pulmonary vascular damage must be excluded. Haemodynamic data such as pressures, flows and resistance ratios are not reliable. According to the majority of Authors the value of pulmonary resistances seems to be more accurate, and when more then 8 u/m2 an histological specimen must be obtained. In our experience a comparative study between the Health and Edwards method and the Yamaki et al., one shows, confirmed by postoperative follow-up, a greater reliability of the second one.

[Peroperative blood autotransfusion in heart surgery]. / L'autoemotrasfusione peroperatoria in chirurgia cardiaca.

A drastic reduction in homologous blood or plasma transfusion becomes necessary to prevent the risks of severe infections disease transmission. The authors studied the possibility of homologous blood save in cardiac surgery by peroperative autotransfusion. This procedure, although it diminished the average blood bank requirements, above all for an unexplained decrease in postoperative bleeding, did not obtain the good results that other authors had with the technique of 2 or 3 preoperative withdrawal, storage and postoperative reinfusion. In future our trend is to associate preoperative and intraoperative withdrawals to take advantage of both techniques.

[Our experience in the treatment of superior vena cava syndrome]. / La nostra esperienza nel trattamento della sindrome della vena cava superiore.

In clinical practice SVC syndrome is an important problem, given both the nature of the disease and its fast lethal evolution. Therapy must be instituted as soon as possible because the chances of a positive result are directly related to the staging of the primary illness. Surgery, chemotherapy and high energy therapy can be used. From the literature, although controversial, the superiority of surgical therapy is clear; particularly if up-to-date vascular reconstruction techniques are employed. From March 1980 to March 1988 8 cases of SVC syndrome were observed in which the aetiology was as follows: Hodgkin's disease (2 cases); secondary catheter thrombosis (1 cases); lung carcinoma (5 cases). The 2 cases of Hodgkin's disease were treated by chemotherapy; the secondary thrombosis by open thrombectomy. In the other 5 cases an innominate vein right appendage by-pass was used (3 PTFE, 2 pericardial grafts). The results were encouraging: complete, long-term remission was observed in the Hodgkin and thrombectomy patients. A PTFE graft thrombosis occurred in 2 cases but in the other cases the by-pass is functioning well at a mean 13 months follow-up.

[Revascularization of the distal arteries of the lower limbs with "in situ" saphenous vein]. / La rivascolarizzazione delle arterie distali degli arti inferiori con safena "in situ".

Over a 3-year period 21 patients underwent "in situ" saphenous vein by-pass graft for lower extremity arterial occlusive disease, all of them with critical ischemia for limb salvage. The proximal anastomosis was performed in all patients end to end to the first segment of the previously endarterectomized superficial femoral artery. The distal graft was taken to the popliteal artery below the knee in 8 cases, to the tibial-peroneal trunk in 4, to the posterior tibial artery in 3, to the peroneal artery in 3, to the anterior tibial artery in 2 and last a sequential posterior tibial-peroneal by-pass graft was performed. The perioperative mortality was nil. The immediate patency rate was 90.5%, while the cumulative patency rate at 36 months was 71.4% overall, 87.5% for the popliteal grafts and 61.1% for the infrapopliteal ones. If we consider that was successful for limb salvage in more than 80% and if the encouraging preliminary results of this technique will be confirmed at a longer follow-up, we believe that this technique could become the procedure of choice for limb salvage even in the high risk patients group.

[Development of lipomas on a surgical wound following radial saphenectomy. An unusual complication]. / Evolution lipomateuse sur plaie chirurgicale après saphénectomie radiale. Une complication exceptionnelle.

Radical saphenectomy is a common practice in treatment of the varicose veins of the limbs, and its early and late complications are very well known. Nevertheless, the authors have observed an exceptional pathologic picture in one patient operated five years ago, which developed multiple nodular lipomas in the sites of the surgical scars for varicectomy. This unusual complication, in spite of lack of clear etiopathogenesis, suggest to reduce as less as possible the surgical subcutaneous traumatism.

[Ranitidine in the treatment of duodenal ulcer. Initial clinical experience with 33 patients]. / La ranitidina nel trattamento dell'ulcera duodenale. Prime esperienze cliniche su 33 pazienti.

The short and medium term results obtained with ranitidine on 33 duodenal ulcer patients are reported. The results obtained indicate that ranitidine is excellent for initial therapy but there are doubts about its efficacity in the prophylaxis of recurring ulceration during maintenance treatment. In addition, about 9% of the patients suffered side effects to the extent that treatment had to be interrupted.