Emergency Treatment of Cervical Vertebromedullary Trauma: 10 Years of Experience and Outcome Evaluation.

OBJECTIVE: The aim of the study is to identify and validate, through the recording of clinical and radiological data, the different surgical approaches and treatments valid for most subaxial cervical dislocation fractures and whether there is an advantage from using an anterior approach rather than a posterior approach and conversely.. MATERIAL AND METHODS: A retrospective study was carried out analyzing the case history of the last 10 years of vertebromedullary traumas treated at the spine surgery unit of the Policlinico Gemelli in Rome. Data on surgical timing, American Spinal Injury Association (ASIA) scores for neurological damage, and subsequent assessments on recovery, survival, and mortality were also examined. RESULTS: A total of 80 patients were treated: 50 by the posterior approach, 24 by the anterior approach, and six by the double approach. Our average follow-up time was 4.2 years. A prevalence of surgery with the posterior approach was noted. We observed the worsening of cervical kyphosis about 15 months after the trauma in two cases treated with the posterior approach alone. A second surgical treatment was performed in these patients. One of these patients underwent an anterior fusion; the other case underwent a posterior revision because the patient had ankylosing spondylitis. Although we found no statistically significant difference in outcomes between the various surgical treatments, in this retrospective study, we analyzed the characteristics and outcomes of cervical spine injuries that required surgical treatment. CONCLUSION: The aim of surgery in unstable cervical spine injuries should be to reduce and stabilize the damaged segment, maintain lordosis, and decompress when indicated. The optimal choice of surgical approach and treatment, or its superiority in terms of outcomes, remains a debated issue.

The effect of combined drug therapy in lateral fragility fractures of the femur: a prospective observational study.

OBJECTIVE: Due to a growing number of lateral fragility fractures, and their high economic and social impact, we evaluated the combined drug therapy effectiveness in lateral fragility femur fractures treated by intramedullary nailing surgery comparing the clinical and radiological results of two groups of patients. PATIENTS AND METHODS: From May 2019 to March 2020, we carried out a prospective observational study comparing the results of patients with femoral lateral fractures treated by the same intramedullary nail (PFNA Synthes®) using Clodronic acid and Vitamin D (study group, 25 patients) compared to patients with the same fractures treated with Vitamin D alone (control group, 25 patients). The evaluations were based on bone biochemical markers (serum calcium level, serum phosphate level, parathyroid hormone, Vitamin D, serum C-terminal telopeptide), Visual Analogic Scale and HHS (Harris Hip Score) score, and femur densitometric views. In order to evaluate the femur neck mineral bone density (BMD), two areas have been identified on the Anterior-Posterior view: the Region of Interest (ROI)1 (under the head screw) and the ROI2 (above the femoral screw). The BMD has been calculated using femur densitometric views at T0 (1st day post-surgery) and at T1 (12 months later). RESULTS: As far as the BMD average of ROI1 is concerned, we found a significant statistical increase at T1 in the study group (0.93±0.07 gr/cm2) vs. control group (0.88±0.08 gr/cm2), p=0.04. Both biochemical and densitometric values were statistically increased in the study group from T0 to T1 (p<0.05), while control group showed an improvement in the biochemical values only. CONCLUSIONS: Thanks to a one year follow-up, we are able to demonstrate that the administration of an adequate drug therapy after surgery can lead to a better control of the bone remodeling and reabsorption process.

Proximal humerus fractures treatment in adult patients with bone metastasis.

OBJECTIVE: The humerus is the second long bone most affected by pathological fractures. According to Capanna and Campanacci criteria, surgical choice is based on bone metastasis location, on the patient's status and on the residual functional capacity. Metadiaphysis is an area of conflict in the choice between megaprosthesis implant and intramedullary nail osteosynthesis. This study compares these two surgical procedures in terms of reacquired functionality and local control of metastasis. PATIENTS AND METHODS: Thirty-eight patients (17 males and 21 females; mean age: 66 years old) treated in our institution between January 2010 and December 2020 for pathological humeral metadiaphyseal fractures caused by metastasis, were included in this study. We choose the Musculoskeletal Tumor Society rating system (MSTS) and the Quick Disability of Arm-Shoulder-Hand (QuickDASH) scores for the evaluation of the upper limb function after surgery. RESULTS: Eighteen (47%) pathological fractures were treated by resection and megaprosthesis implantation, twenty (53%) were treated by medullary nail osteosynthesis. A reduction in pain and greater mechanical stability in the immediate post-operative period was found in all patients. Twenty-two patients died (58%) and sixteen survived (42%). Long-term functional recovery of patients undergoing osteosynthesis is greater than megaprothesis group. CONCLUSIONS: Both medullary nail osteosynthesis and resection and megaprosthesis implantation guarantee excellent recovery at 72 months after surgery, improvement in quality of life and pain relief.  Patients treated with osteosynthesis showed a great short-term functional recovery since the joint portion of the limb is not involved, whereas patients treated with megaprosthesis showed better local oncologic control. It is therefore possible to define the type of treatment not only on the localization of the fracture (diaphysis or epiphysis) but above all on the conditions and characteristics of the patient.

Residual mobility after removal of instrumentation in patient, with type a2-a3 vertebral fractures, treated with percutaneous pedicle screw fixation.

Percutaneous techniques for treatment of thoraco-lumbar fractures type A2 and A3 are widely used. These techniques are considered temporary fixations and instrumentation must be removed with fracture healing. The aim of the study is to analyze clinical results, motility of treated segments and any loss of correction after the removal of instrumentation. We evaluated 36 patients who underwent surgery for removal of the instrumentation. Standard and dynamics x-ray before surgery and at 1 and 12 months after surgery were obtained. Radiographic evaluation was performed by comparing loss of correction after removal of the instrumentation, residual mobility of fractured vertebra, upper and lower level with values defined by Dvorak. For clinical assessment were used SF-12, Oswestry Disability Index (ODI) and Visual Analog Scale (VAS), administered before surgery and at 1 and 12 months after the removal. We analyzed a total of 108 levels in 36 patients. After removal of the instrumentation a normal range of motion was restored in the proximal and distal segment of the fracture, while at level of fractured segment we noticed a decrease in motility. Clinically, patients had a significant decrease in VAS and ODI at 1 month after removal. Our study shows that percutaneous fixation for treatment of thoraco-lumbar fractures type A2 and A3, allows to preserve motility of the treated segments after the removal of the instrumentation until 12 months. The removal of instrumentation is associated with good clinical results without of loss of correction in treated segment.

The use of custom-made antibiotic-loaded spacer in periprosthetic knee infection caused by XDR organism: case report and review of literature.

Periprosthetic knee infection (PKI) remains one of the most challenging complications after total knee replacement, especially if caused by multidrug-resistant (MDR) or extensively drug-resistant (XDR) organisms. Multiple treatment options are available, such as long-term antibiotic suppression, surgical debridement with retention of the prosthesis, definitive resection arthroplasty, arthrodesis, one-stage or two-stage revision procedures, amputation. We present a rare case of a PKI caused by a XDR Klebsiella pneumoniae in a young patient who underwent a prosthetic reconstruction due to an osteosarcoma of the tibia. In this patient, the PKI has been treated using intravenous administration of Amikacin and an Amikacin-impregnated PMMA custom-made spacer. To our knowledge, only two cases that successfully used hand-mixed antibiotic-loaded spacer based on antibiotic sensitivity for the treatment of PKI caused by MDR and XDR microorganisms have been reported in the literature.

A study of 44 patients with subtrochanteric fractures treated using long nail and cerclage cables.

OBJECTIVE: This study aims to demonstrate that the use of long cephalomedullary nail and cerclage cables represents a good strategy in order to reduce the high risk of nonunion of the most displaced subtrochanteric fractures. METHODS: This retrospective study examines 44 patients with average follow-up of 23 months, with subtrochanteric fracture type SH IIB, IIC, IIIA, IIIB treated by the same operator and with the same nail and cerclage cables. The clinical results which are derived from THRS have been reported. RESULTS: Clinical and radiological consolidation occurred in all 44 cases, without re-intervention. The average evaluation derived from the THRS was 48 which corresponds to good, according to the scale. CONCLUSIONS: Considering the anatomic reduction achieved in all patients and the clinical results, we can define the use of long cephalomedullary nail and cerclage cables as the most useful technique in the armamentarium of a trauma surgeon for the treatment of the subtrochanteric fractures.

Fetal cystic hygroma: the importance of natural history.

OBJECTIVES: To evaluate the natural history of cystic hygroma (CH) in fetal and neonatal periods to enrich parental counselling. Ultrasonographic characteristics, associated syndromes, chromosomal anomalies, fetal cardiac pathology and life after birth were considered. STUDY DESIGN: From May 1985 to September 2010, 207 pregnancies were seen the authors' centre with suspected vascular-lymphatic fetal malformation: 156 of them had CH. Cases were followed up by telephone interview to determine fetal and neonatal outcomes. Chi-squared test was used for statistical analysis. RESULTS: Among the 156 cases of CH, the condition was septated in 75% of cases, associated with other pathologies in 74%, and retronuchal in 88%. Intrauterine regression was seen in 36% of cases, with complete disappearance in 77%. The karyotype was normal in 55% of cases. Follow-up was completed in 85 cases and revealed 54 spontaneous abortions (63%) and 31 live births (37%). Amongst these, 21 out of 31 children had a favourable outcome (68%). A negative embryo-fetal outcome was significantly associated with CH being associated with other pathologies, such as hydrops, retronuchal position and altered karyotype. Spontaneous regression or resolution of CH was associated with live births. CONCLUSIONS: The management of pregnancies with a diagnosis of fetal CH requires knowledge of natural history of the malformation for appropriate parental counselling.

In-utero stem cell transplantation: clinical use and therapeutic potential.

Early evidence suggests that in-utero stem cell transplantation represents a new therapeutic strategy for different congenital disease. Moreover, gene therapy constitutes one of the most promising new approach to treat a wide spectrum of genetic disorders. It was shown that the fetus could represent an ideal recipient because of his immunologic early naiveté in gestation that reduces the risk of immunoreactions. Clinical experience in human fetus was performed in order to treat immunodeficiency and metabolic disorders, hemoglobinopathies and some other genetic diseases. Use of alternative source (i.e., cord blood, placenta, membrane, amniotic fluid, fetal tissue) of stem cell transplanted has been only one of the several strategies to improve donor cell advantages on host stem cell. The present review focused on the clinical use and therapeutic potential of in-utero stem cell transplantation, reporting the outcome of human cases treated and the limits of this therapy and possible future applications.

Source of cell injected is a critical factors for short and long engraftment in xeno-transplantation.

This study aims to investigate engraftment of human cord blood and foetal bone marrow stem cells after in utero transplantation via the intracoelomic route in the sheep. Here, we performed transplantation in 14 single and 1 twin sheep foetuses at 40-47 days of development, using a novel schedule for injection. (i) Single injection of CD34(+) human cord blood stem cells via the coelomic route (from 10 to 50 x 10(4)) in seven single foetuses. (ii) Single injection of CD34(+) foetal bone marrow stem cells via the intracoelomic route with further numbers of cells (20 x 10(5) and 8 x 10(5), respectively) in three single and in one twin foetuses. (iii) Double fractioned injection (20-30 x 10(6)) via the coelomic route and 20 x 10(6) postnatally, intravenously, shortly after birth of CD3-depleted cord blood stem cells in four single foetuses. In the first group, three single foetuses showed human/sheep chimaerism at 1, 8 and 14 months after birth. In the second group, the twin foetuses showed human/sheep chimaerism at 1 month after birth. In the third group, only two out of four single foetuses that underwent transplantation showed chimaerism at 1 month. While foetal bone marrow stem cells showed good short-term engraftment (1 month after birth), cord blood stem cells were able to persist longer in the ovine recipients (at 1, 8 and 14 months after birth).

Fertility rate evaluation by laparoscopic approach in the experimental animal.

PURPOSE OF INVESTIGATION: The aim of the present study was to evaluate the effect of laparoscopic insemination (LAP) and natural mating (NM) on fertility rate in experimental animal (Ovis Aries Comisana) during the month of June. METHODS: For the experiment, 97 ewes were used. Laparoscopic insemination was performed with the frozen semen of three different Romanov rams: Laparoscopic insemination I (n = 24); Laparoscopic insemination 2 (n = 26); and laparoscopic insemination 3 (n = 28), and natural mating was performed with two different Ovis Aries Comisana rams with proven fertility: Natural mating I (n = 10); Natural mating 2 (n = 9). Estrus was synchronized with fluorogestone acetate impregnated intravaginal sponges (40 mg, 14 days). Pregnant mare serum gonadotrophin (Folligon, Intervet International) at a dose of 400 UI was given intramuscularly at sponge removal. Artificial insemination was carried out 60 hours after the removal of the sponges in the laparoscopic insemination groups. RESULTS: The mean pregnancy rate at ecographic diagnosis performed at about 36 days from sponge removal for the laparoscopic insemination and natural mating groups were respectively, 62.8% and 78.9% with no significant difference. CONCLUSION: The mean fertility rates for the LAP and NM groups were 56.0 and 73.4, respectively, with no significant difference.

Ovine fetal growth curves in twin pregnancy: ultrasonographic assessment.

PURPOSE OF INVESTIGATION: The fetal-lamb model is a fundamental tool for developing clinical applications for the treatment of human fetal pathology (e.g., open fetal surgery). Accurate estimation of gestational age is important to avoid size-related problems during surgery. METHODS: To evaluate the effect of twinning on ovine fetal growth, we followed seven twin pregnancies in Comiso ewes from mating through parturition. Fetal growth indexes (muzzle-occipital and mean abdominal diameters, abdominal circumference, femoral and humeral length) were measured weekly using perimammary ultrasonography and analyzed with a linear quadratic regression model based on natural logarithms of each parameter and fetal age. RESULTS: The model explained > 90% of the variability observed, with determination coefficients of 95% (femoral length, abdominal circumference), 94% (abdominal diameter, humeral length), and 89% (muzzle-occipital diameter). CONCLUSION: Mean birth weight was lower than that reported for singleton fetal lambs, as it is in bigeminal pregnancies in humans, despite the uterine and placental differences between these two species. With the exception of slightly earlier growth deceleration, curves for head and long-bone growth resembled those for singleton ovine fetuses. Ovine fetal growth patterns (like those of humans) in singleton and twin pregnancies are similar.

Fetal surgery for spina bifida aperta: to be or not to be?

Fetal SBA (spina bifida aperta) has been operated upon in more than 213 cases in the USA in the last 8 years. Indications and results still remain controversial. Our group reproduced successfully Meuli's model in sheep and reviewed the literature on SBA and the Internet updated sites on the theme. Then we reviewed the follow-up of all cases operated upon postnatally in 20 years at a Neurosurgery Department in Rome. We published all the data regarding the three above-mentioned steps. This paper contains reflections on the three, and our opinion on the correct approach to prenatally diagnosed SBA, as far as fetal surgery is concerned.

Congenital cystic adenomatoid malformation of the lung: antenatal ultrasound findings and fetal-neonatal outcome. Fifteen years of experience.

Seventeen cases of congenital cystic adenomatoid malformation of the lung (CCAM) are reported. They were followed up over a period of 1 month to 15 years. Diagnosis was made by prenatal ultrasound. Our purpose was to evaluate the fetal-neonatal outcome and the prognostic elements observable through ultrasound techniques, and to compare all types of CCAM. The outcome observed ranged from total prenatal resolution to postnatal spontaneous regression of the lesion, to complications due to the presence of nonimmune fetal hydrops (NIFH), intrauterine death and the necessity of surgical intervention. In our experience only hydrops represented a negative predictor of outcome since death occurred in all cases with this pathology. In the absence of NIFH, counselling should stress the prevalence of a positive outcome, even in cases of surgical intervention.

Multimodal approach in invasive fetal therapy.

BACKGROUND: Integrated fetal therapy is a new approach to prenatal management consisting of a combination of invasive procedures which complement each other to provide as much information as possible on the fetal compartments. METHODS: We carried out a study on 50 fetuses of singleton pregnancies undergoing invasive procedures -- at least three per fetus -- for diagnostic and therapeutical purposes. A total of two hundred and fifty invasive procedures were adopted. The study population was divided into two groups, those studied between 1988 and 1992 and those studied between 1993 and 1995. RESULTS: The diagnostic and therapeutic utility of complementary invasive procedures in fetuses with nonimmune fetal hydrops and urinary tract malformations was assessed. In fetuses with nonimmune fetal hydrops integrated invasive procedures markedly affected the fetal-neonatal survival rate, whereas in those with urinary tract malformations scheduled for postnatal surgery these procedures made it possible to limit intrauterine renal damage. CONCLUSIONS: Complementary invasive procedures in NIFH fetuses particularly influence the fetal-neonatal survival rate. Since urinary tract malformations must be treated by postnatal surgery, complementary invasive procedures serve to limit intrauterine renal damage in the meantime and to reduce cesarean section rate.

Fetal tissue collection from spontaneous abortions: a report from a single centre.

Due to immunological immaturity, the fetus is the ideal recipient as well as donor of haemopoietic stem cells (HSCs); thus intrauterine therapy may prove to be effective in all major haemopoietic disorders when early prenatal diagnosis is available. In man, "fetus-to-fetus" transplantation has demonstrated the possibility of grafting donor HSCs and reconstituting immunodeficient fetuses. The limitations of fetal tissue use for transplantation derive from the origin of tissues from elective abortions. Early and late live spontaneous abortions may constitute an alternative to elective abortions, but are widely considered as unsuitable for fetal tissue collection because of rapid loss of viability and/or infections. The aim of this retrospective study was to assess the number of live abortions in a population of women who underwent spontaneous abortion in a single centre. In a 19-month period, 9 spontaneous abortions alive at the moment of delivery and 8 with a heart beat at the last ultrasound scan before abortion were recorded. In 1 case, fetal liver (FL) harvesting was easily performed and the tissue was cryopreserved, subsequently thawed and injected into a monkey fetus. This case shows the feasibility of this approach. The majority of cases reviewed consisted of late abortions. These findings clearly show that fetal tissue collection from spontaneous abortions is feasible for research purposes, for postnatal FL transplantation and for intrauterine transplantation, postnatal FL transplantation and for intrauterine transplantation, provided that depletion of more mature cells is performed when FL of later gestational age are used.(ABSTRACT TRUNCATED AT 250 WORDS)

[Neonatal abstinence syndrome and maternal toxicological profile]. / Sindrome d'astinenza neonatale e profilo tossicologico materno.

Neonatal abstinence syndrome (NAS) is one of the most frequent manifestations in the neonates of drug-addicted mothers. It is caused by the abrupt interruption of the transplacentar passage of drugs from the mother to the fetus. The aim of this study was to evaluate the correlation between drugs taken during pregnancy and NAS. Data were examined relating to 223 neonates born during 1975-1992 to drug-addict mothers. Neonates were subdivided into four groups according to the maternal toxicological profile. It was thus possible to observe that there is a greater prevalence of NAS in cases of polypharmacomania and that it gradually diminishes in the children of heroin addicts and those receiving methadone treatment. Moreover, the intensity of the syndrome is correlated to the high doses of methadone and/or heroin. In the group of neonates whose mothers had complied with the methadone treatment protocol, the severity of NAS was proportional to the dose taken by the mother. In conclusion, the management of pregnant drug addicts following a controlled methadone treatment programme is accompanied by improved obstetric help and is the most suitable way of reducing perinatal complications and the prevalence of NAS.

[Usefulness and limits of the ultrasonic examination in the diagnosis and prognosis of early pregnancies with vaginal bleeding]. / Validità e limiti dell'esame ecografico nella diagnosi e nella prognosi di gravidanze iniziali con perdite ematiche vaginali.

At the Department of Obstetrics and Gynecology of Catholic University in Rome 1257 pregnancies with vaginal bleeding in the first or second trimesters were ultrasonically observed. Pregnancy was found to be in normal development in 538 cases (42.80%); spontaneous abortion was reported in 688 cases (54.73%) and ectopic pregnancy, confirmed at surgery, in 31 cases (2.47%). The duration of bleeding appeared to have a significant effect on the prognosis of the pregnancy. Bleeding for 4 days or more predicted abortion almost significantly more often than a shorter bleeding episode. The spontaneous abortion rate increased with advancing maternal age and decreased with advancing gestational age. After detection of fetal life signs, the pregnancies ended in later abortion only in 9.29% of the cases. In this case there are no significant differences between normal or abnormal ultrasonic examinations. In our experience the ultrasound scanning, in patients with early pregnancy bleeding, is able to differentiate between live gestation or abortion but cannot predict the future.

Drug abuse in pregnancy: fetal growth and malformations.

The influence of drug addiction in pregnancy on the fetus is in terms of malformation, ponderal and functional development and post-natal psychoneuromotor development. The Authors evaluate the incidence of this complications in 101 drug addicted pregnant patients and the results are shown below.

Antenatal ultrasonic demonstration of congenital diaphragmatic hernia.

Prenatal demonstration of congenital diaphragmatic hernia is described. Planned, early treatment is made possible with improvement of survival.