Exploring the impact of rehabilitation on post-surgical recovery in elbow fracture patients: a cohort study.

INTRODUCTION: Elbow fractures, characterized by their complexity, present significant challenges in post-surgical recovery, with rehabilitation playing a critical role in functional outcomes. This study explores the efficacy of rehabilitative interventions in enhancing joint range of motion (ROM) and reducing complications following surgery for both stable and unstable elbow fractures. METHODS: A cohort of 15 patients, divided based on the stability of their elbow fractures and whether they received post-operative rehabilitation, was analyzed retrospectively. Measurements of ROM-including flexion, extension, pronation, and supination-were taken at three follow-ups: 15-, 30-, and 45-day post surgery. The study assessed the impact of rehabilitation on ROM recovery and the resolution of post-surgical complications. RESULTS: The findings indicated no statistically significant differences in ROM improvements between patients who underwent rehabilitation and those who did not, across all types of movements measured. However, early rehabilitative care was observed to potentially aid in the mitigation of complications such as joint stiffness, especially in patients with stable fractures. CONCLUSION: While rehabilitation did not universally improve ROM recovery in elbow fracture patients, it showed potential in addressing post-operative complications. The study underscores the importance of individualized rehabilitation plans and highlights the need for further research to establish evidence-based guidelines for post-surgical care in elbow fractures.

Technology applications in shoulder replacement.

The advancement of technologies in orthopaedic surgery should provide the surgeon with precise and trustworthy support for pre-operative planning, intra-operative guidance and post-operative follow-up. The request for greater accuracy, predictable results and fewer complications, is the engine of digital evolution in pre-operative planning and computer-assisted surgery (CAS). It is an evolution rather than a revolution, and in the last few years these developments have begun to involve shoulder replacement surgery, too.

Distal biceps tendon rupture: advantages and drawbacks of the anatomical reinsertion with a modified double incision approach.

BACKGROUND: Distal biceps tendon rupture occurs more often in middle-aged male population, involving the dominant arm. In this retrospective study, it's been described the occurrence of the most frequent adverse events and the clinical outcomes of patients undergoing surgical repair of distal biceps tendon rupture with the modified Morrey's double-incision approach, to determine better indications for patients with acute tendon injury. METHODS: Sixty-three patients with acute distal biceps tendon rupture treated with a modified double-incision technique between 2003 and 2015 were retrospectively evaluated at a mean 24 months of follow-up. Clinical evaluation including range of motion (ROM) and isometric strength recovery compared to the healthy contralateral side assessment, together with documentation of nerve injury, was performed. Patients were asked to answer DASH, OES and MEPS scores. RESULTS: The ROM recovery showed excellent results compared to the healthy contralateral side. The reported major complications included: one case of proximal radio-ulnar synostosis, 3 cases of posterior interosseous nerve (PIN) palsy and one case of a-traumatic tendon re-rupture. Concerning minor complications, intermittent pain, ROM deficiency < 30° in flexion/extension and pronation/supination, isometric flexion strength deficiency < 30% and isometric supination strength deficiency < 60%, lateral antebrachial cutaneous nerve (LACBN) injury, were observed. The average DASH score was 8.5; the average OES was 41.5 and the MEPS was 96.3. CONCLUSION: The Morrey modified double-incision technique finds its indication in young and active patients if performed within 2 weeks from injury. If performed by experienced surgeons, the advantages can exceed the drawbacks of possible complications.

Mason type III radial head fractures treated by anatomic radial head arthroplasty: Is this a safe treatment option?

BACKGROUND: Radial head fractures make up approximately 3% of all fractures and they are the most common elbow fracture in adults. Replacement through arthroplasty is the recommended treatment in the context of unstable elbow injury and comminuted radial head fracture. The midterm clinical, functional, and radiographic results in patients treated with anatomic radial head arthroplasty for a Mason type III radial head fracture are presented. MATERIAL AND METHODS: We performed a retrospective search of our facility's prospective trauma database to identify all skeletally mature patients who were treated by primary radial head replacement or open reduction and internal fixation following an acute radial head fracture. Inclusion criteria were Mason type III fractures and anatomic radial head arthroplasty (RHA). All the patients included were evaluated using a standard postoperative protocol including clinical and radiographic evaluation at 1, 3 and 12 months of follow-up. All the patients were reviewed clinically at an average of 30 months' follow-up. RESULTS: Forty-one subjects (32 Mason type III and 9 Mason IV fractures) were treated with anatomic RHA (Acumed, Hillsboro, OR, USA). Of these, two patients (1 Mason type III and 1 Mason type IV) were excluded from the analysis because severe cognitive impairment. Moreover, we decided to exclude the subjects with a Mason type IV fracture to obtain a more homogeneous sample. Therefore, 31 patients with a Mason type III fracture were included in this study. Based on the Mayo Elbow Performance Score, excellent results were obtained in 24 (77%) patients, good in 3 (10%) and fair in 4 (13%) patients. Heterotopic ossification was reported in 8 patients (26% of cases). The final elbow flexion-extension range of motion was of 112°, with a mean flexion of 125°. The final forearm rotational range of motion was 134° with a mean pronation of 68° and a mean supination of 66°. DISCUSSION: Anatomic radial head replacement leads to a good functional recovery, even in the presence of severe instability, such as coronoid fractures and LUCL injury. However, patients should be informed of the high number of adverse events (mainly heterotopic ossification) following this treatment. LEVEL OF EVIDENCE: Therapeutic IV.

Humerus shaft fracture complicated by radial nerve palsy: Is surgical exploration necessary?

Fractures of the humerus shaft often are complicated by radial nerve palsy. Controversy still exists in the treatment that includes clinical observation and eventually late surgical exploration or early surgical exploration. Algorithms have been proposed to provide recommendations with regard to management of the injuries. However, advantages and disadvantages are associated with each of these algorithms. The aim of this study was to analyze the indications of each treatment options and facilitate the surgeon in choosing the conduct for each lesion, proposing our own algorithm.

Double-locking precontoured plating system for malunited fractures of the distal end of humerus.

BACKGROUND: Distal humeral malunions are uncommon injuries, often associated with limited elbow motion, pain, instability, weakness, and sometimes ulnar neuritis. The complex anatomy of the elbow joint makes this condition one of the most complex elbow injuries to treat. MATERIALS AND METHODS: Four patients were treated by the same surgeon between 2011 and 2013 using a double-locking precontoured plating system for malunited intra-articular or extra-articular fractures of the distal end of the humerus. RESULTS: At a mean 3 years of follow-up, a significant improvement in the elbow motion and functional outcome, evaluated with the Mayo Elbow Performance Index and the Disability of the Arm, Shoulder, and Hand, were observed. Articular reduction obtained after the surgery was maintained in all patients without evidence of avascular necrosis. No other complications (i.e., infection, nervous iatrogenic lesions) were reported. CONCLUSIONS: Corrective osteotomy using double-locking precontoured plating system preceded by preoperative planning using a CT scan allowed an improvement in the functional outcome and elbow motion, without complications.

Scapholunate interosseous ligament injury in professional volleyball players.

Injuries to the scapholunate interosseous ligament (SLIL) are the most common cause of carpal instability. A SLIL injury typically follows a fall on an outstretched hand, with the wrist in hyperextension, ulnar deviation and intercarpal supination. We hypothesize that repetitive axial loading on the wrist in hyperextension, during the reception and digging motions of volleyball, can lead to functional overloading of the SLIL. To identify patients and to determine the clinical history and surgical treatment performed, we analyzed hospital records, X-rays, electronic databases containing all the operations performed, and image files (including before and after surgery and follow-up). We identified three SLIL injury cases in national volleyball team players, also at the libero position, who were treated at our clinic between 2007 and 2013 for scapholunate instability. Open reduction and Berger capsulodesis was performed in all cases. At a mean follow-up of 3 years (range, 22-50 months), the mean pain level on VAS was 0.3 (range, 0-1) at rest and 1.7 (range 1-2) during sport activities. The mean DASH score was 4 (range 2-5). The mean wrist flexion was 60° (range 55-70°) and extension was 80° (range 75-85°). Given the greater susceptibility of these players for developing a SLIL injury, a high index of suspicion is needed when managing athletes presenting with wrist pain or instability.

Shear fractures of the distal humerus: Is the use of intra-articular screws a safe treatment?

BACKGROUND: Coronal shear fractures of the distal humerus are uncommon injuries and are not exempt from complications. The aim of this research is to evaluate the possible advantages and drawbacks using cannulated compression headless screws. MATERIALS AND METHODS: We performed a prospective study including all the consecutive patients who were treated with cannulated screws for coronal shear fractures of the distal humerus between 2010 and 2013. Following the Dubberley's classification, three patients were type 1A, one patient was 1B, three patients were 2B, and one patient was 3B. The mean follow-up was 30 months. The clinical and radiological evaluation included analysis of passive range of motion, functional outcome, radiological evaluation of fracture healing and reduction maintenance, and the occurrence of possible adverse events. RESULTS: All fractures healed, and radiographic union was observed at an average of 3 months. The average elbow range of motion was 125°, with 125° of flexion and 20 of extension. According to the Broberg and Morrey score, there were four excellent and four good results. Using the Mayo Elbow Performance Index, five cases achieved excellent scores and three reported good results. Adverse events reported in three cases were as follows: heterotopic ossification, complex regional pain syndrome and delayed lateral collateral ligament disruption. CONCLUSIONS: The use of cannulated compression headless screws has given satisfactory results, allowing a strong inter-fragmentary compression, early mobilization, with high union rates and good elbow function. However, patients should be counseled about the high proportion of adverse events following these injuries.

The treatment of distal radius articular fractures of C1-C2 type with DVR plate: analysis of 40 cases.

The aim of this investigation was to evaluate the efficiency of fixed angle plates DVR in the treatment of C1 and C2 type articular wrist fractures according to the AO classification. From July 2005 to March 2009, 40 wrist fractures were treated: 18 were of C1 type while 22 of C2 type according to AO classification. The age of patients varied from 25 to 79 years old. The average length of follow-up was 17 months (range, 4-37 months). The average articular motility was flexion 59.4° and extension 62.7°. Final radiographic parameters were of 18.7° of average ulnar inclination, 10.3° of average dorsal inclination, and 1.45 mm of negative ulnar variance. All patients were reassessed according to Mayo Modified Wrist Score getting a very good/good result in 82% of cases and a medium/poor one in 18%. The DASH score pulled off 46.3 points in the first group, 5.1 in the second group, and 6 in the third one. The statistical analysis based on Student's t test showed how C1 and C2 classification did not influence the results using the same treatment. DVR plate showed a very good reliability and a sufficient stability with both C1 and C2 fractures.

The treatment of distal radius articular fractures through lcp system.

We analysed LCP efficiency in type B and type C wrist fractures (according to the AO Classification). We treated 58 wrist fractures (19 B-type fractures and 39 C-type fractures) in 35 male and 23 female patients, aged 19 to 87 years. Forty-one cases were followed up for an average period of 13 months. We performed a volar approach on 32 patients, a dorsal approach on five, and a double approach on four (both volar and dorsal). Twenty-six cases were pre-operatively examined with CT. All patients were evaluated using the "Mayo modified wrist score", with an excellent/good result in 76% of patients and a satisfactory/poor result in 24%. The LCP system proved to be adequately reliable and stable to keep the reduction in complex fractures (e.g. the C-type fractures in patients with low bone quality).

Treatment of fingertips amputation using the Hirase technique.

The management of very distal finger amputations when the amputated part is saved is still difficult and controversial. Both re-attachment of the amputated portion as a composite graft and microvascular anastomosis can fail in this distal location. Replantation is, in fact, associated with certain problems, such as technical difficulty, risk of failure because of the poor venous drainage, and costs. With the exception of children, amputations at the level of the lunula poorly survive direct re-attachment. Hirase has described a new replantation model without vascular anastomosis and used ice water and aluminium foil to enhance survival of the composite graft. Cooling the entire recipient site retards cellular degeneration in the graft until neovascularisation occurs. The present authors applied this method to seven cases in which a digit had been amputated between the tip and the lunula. In four cases the method proved to be completely successful, whereas in two an area of tip necrosis was observed. The Hirase method has proven to be a simple and reliable surgical technique for fingertip re-attachment.

Management of neuromas in continuity of the median nerve with the pronator quadratus muscle flap.

Treatment of painful neuromas in continuity of the median nerve at the wrist level is a challenging problem. Nine median nerve neuromas were covered with the pronator quadratus muscle preelevated as an island flap. Patients were followed for 10 to 60 months after surgery. Results showed a marked improvement in terms of symptoms in all patients. In particular, 6 patients had complete pain relief and 3 patients complained of mild intermittent pain.

Tendinous cutaneous dorsal hand injuries. One-stage reconstruction.

The reconstruction of complex cutaneous tendinous dorsal hand injuries represents a problem that is not easy to solve. The transferral in a single surgical stage, with a single flap, of skin, tendons, and nerves, all completely vascularized, is probably the ideal solution. Between 1988 and 1999 the one-stage reconstruction method was used in 13 patients. A cutaneous tendinous dorsalis pedis free flap was used in 7 cases, and a cutaneous tendinous radial forearm island flap with an inverted flow was used in 6. The dorsalis pedis flap allows for the inclusion of 4 tendons that are completely vascularized (extensor digitorum communis), while the radial flap allows us to completely insert a single tendon (palmaris brevis) and two vascularized tendinous strips taken from the flexor carpi radialis and from the brachioradialis. All of the flaps transferred survived perfectly with good functional recovery. One-stage reconstruction that is "completely vascularized" allows us to reduce the amount of time spent in hospital, the number of operations, and above all it provides cosmetic and functional results that are close to normal. The dorsalis pedis flap is indicated in cases of cutaneous tendinous dorsal hand injuries that require the simultaneous reconstruction of three or four extensor tendons. On the other hand, the radial flap may be used in situations where it is necessary to reconstruct only 1 or 2 tendons.

Island radial artery fasciotendinous flap for dorsal hand reconstruction.

The authors report a one-stage repair for a dorsal hand injury that involves the loss of skin and tendons. The injury was repaired using an island radial artery flap complete with fascia and tendons, leaving the forearm skin behind. The functional and aesthetic results are excellent, and there was minimal donor site morbidity.

Iron deficiency and intestinal malabsorption in HIV disease.

Children with human immunodeficiency virus (HIV) infection have a higher prevalence of intestinal malabsorption. Anemia is also a common feature in these children. The aims of this work were (a) to establish the prevalence of iron deficiency in HIV-infected children, (b) to test the hypothesis that iron deficiency is related to intestinal malabsorption, (c) to see whether it may contribute to anemia, and (d) to evaluate the sensitivity of oral iron load in the investigation of intestinal function. To accomplish these goals, 71 HIV-infected symptomatic children were enrolled. Iron serum values were determined before and after oral load with ferrous sulfate. The correlation between basal and post-load iron levels was evaluated by linear regression. Xylose level after oral load, fecal fat, and fecal alpha 1-antitrypsin concentration were also determined. Iron deficiency was detected in 48% of patients, and it was significantly associated with intestinal iron malabsorption. Sugar malabsorption, steatorrhea, and fecal protein loss were detected in 26, 36, and 17% of patients, respectively. Low hemoglobin levels were detected in 66% of patients. The majority of children with iron deficiency also had anemia. Preliminary data showed that oral iron administration was sufficient for raising hemoglobin in children with normal iron absorption, whereas parenteral administration was required in those with iron malabsorption. We conclude that (a) iron deficiency is a major feature of pediatric HIV infection, (b) it is related to intestinal malabsorption, and (c) it contributes to anemia. Finally, oral iron load is a sensitive test for investigating intestinal function.

Characteristics and mechanism of action of a heat-stable enterotoxin produced by Klebsiella pneumoniae from infants with secretory diarrhea.

Escherichia coli heat-stable enterotoxins (ST) are classified into STa and STb according to their physicochemical and biologic characteristics. STa induces diarrhea, activating the guanylate cyclase-cGMP system. ST-like enterotoxins can be produced by bacteria other than E. coli, including Klebsiella pneumoniae. A Klebsiella ST has previously been shown to share some chemical and immunologic characteristics with E. coli ST. Aiming to define better the nature of Klebsiella ST, we have screened 237 children with diarrhea and 179 controls for ST-producing Klebsiella, using the SMA. We detected 26 Klebsiella strains from patients, two of which were positive in the SMA, and 36 from controls, all negative for ST. A partial purification was performed using an acetone precipitation followed by ultrafiltration and gel filtration techniques. Klebsiella toxin was heat-stable, methanol-soluble, sensitive to mercaptoethanol, active at acid pH values, but not at pH greater than 8. The time course of Klebsiella toxin in the SMA resembled that of E. coli STa. Klebsiella ST caused reduced Na absorption and net Cl secretion in rabbit ileal mucosa mounted in Ussing chambers. It was found to increase the cGMP but not the cAMP concentration. Finally, Klebsiella ST did not react with anti-E. coli STa MAb in a competitive ELISA. We conclude that K. pneumoniae may induce diarrhea through the production of an STa similar but not identical to E. coli STa.

[Multifocal cancer of the breast. Considerations on the mammographic diagnosis]. / Il cancero plurifocale della mammella. Considerazioni di diagnostica mammografica.

A review is carried out of a series of mammographic investigations in 687 tumours observed at the Pascale Institute, Naples, between 1972 and 1977. Mammography shows in a high percentage of cases a multifocality of the disease which was unsuspected. This allows a better evaluation of the stage of the tumour and a correct therapeutic programme.

[Bone marrow scanning (author's transl)]. / La scintigrafi midollare ossea

Personal experience of Technetium-99m-sulfur colloid in the scintiscanning of bone marrow is reported. The method offers technical advantages over other methods and superior protection, while its only limitation is that it does not permit a dynamic study of hematopoiesis. Four pathologic scans typical of four groups of diseases may be distinguished. Further, metastatic bone marrow localisations can be diagnosed much earlier and more precisely than by radiography.