An Overview on Carbon Quantum Dots Optical and Chemical Features.

Carbon quantum dots are the materials of a new era with astonishing properties such as high photoluminescence, chemical tuneability and high biocompatibility. Since their discovery, carbon quantum dots have been described as nanometric high-fluorescent carbon nanoparticles, but this definition has become weaker year after year. Nowadays, the classification and the physical explanation of carbon quantum dots optical properties and their chemical structure remain matter of debate. In this review, we provide a clear discussion on these points, providing a starting point for the rationalization of their classification and a comprehensive view on the optical and chemical features of carbon quantum dots.

An unusual case of extra-nodal interdigitating dendritic cell neoplasm: sarcoma or not?

INTRODUCTION: Interdigitating dendritic cell sarcoma (IDCS) represents an extremely rare neoplasm frequently originating from T-cell- associated dendritic antigen-presenting cells normally populating the paracortex of lymph nodes. Diagnosis is challenging due to the rarity of this neoplasm and the overlapping features with the other primary and metastatic spindle cell neoplasm, even more, when localized in an extra-nodal site. PATIENTS AND METHODS: Herein we report a case of 48 Years old woman with a six-month history of centimetric, quiet painful mass of the philtrum without other significant comorbidity. RESULTS: Histological report showed a proliferation of quiet bland spindle to plump cell, scattered multinucleated giant cell in a subtle background of lymphocytes. IHC study displays only positivity for S-100 and fine, granular scattered cytoplasmatic stain for CD68; all dendritic IHC markers were negative. Morphological and immunohistochemical analyses were consistent with extra-nodal Interdigitating Dendritic Cell Neoplasm. CONCLUSION: Interdigitating Dendritic Cell Sarcoma is a rare and challenging entity with a variable prognosis. We present a case of extra-nodal IDCS whit low worrisome histological features, emphasizing the need for further efforts to better definitely this rare neoplasm ad its potential for malignancy.

Number and brightness analysis reveals that NCAM and FGF2 elicit different assembly and dynamics of FGFR1 in live cells.

Both fibroblast growth factor-2 (FGF2) and neural cell adhesion molecule (NCAM) trigger FGF receptor 1 (FGFR1) signaling; however, they induce remarkably distinct receptor trafficking and cellular responses. The molecular basis of such a dichotomy and the role of distinct types of ligand-receptor interaction remain elusive. Number of molecules and brightness (N&B) analysis revealed that FGF2 and NCAM promote different FGFR1 assembly and dynamics at the plasma membrane. NCAM stimulation elicits long-lasting cycles of short-lived FGFR1 monomers and multimers, a behavior that might reflect a rapid FGFR1 internalization and recycling. FGF2, instead, induces stable dimerization at the dose that stimulates cell proliferation. Reducing the occupancy of FGFR1 in response to low FGF2 doses causes a switch towards cyclically exposed and unstable receptor dimers, consistently with previously reported biphasic response to FGF2 and with the divergent signaling elicited by different ligand concentrations. Similar instability was observed upon altering the endocytic pathway. Thus, FGF2 and NCAM induce differential FGFR1 clustering at the cell surface, which might account for the distinct intracellular fate of the receptor and, hence, for the different signaling cascades and cellular responses.

Treatment of CSF leakage and infections of dural substitute in decompressive craniectomy using fascia lata implants and related anatomopathological findings.

PURPOSE: Decompressive craniectomy (DC) is widely used to treat raised intracranial pressure (ICP) in cranial trauma and stroke. It is accompanied by numerous complications. The aim of our study is to assess the surgical treatment of infections related to the use of a dural substitute with concurrent CSF leakage performed at our institution. MATERIAL AND METHODS: A retrospective analysis of a series of 72 patients who underwent DC between 2011 and 2017 was performed. Seven cases (9%) showed infection related to the use of xenograft (bovine pericardium) and coexisting CSF leakage. Epidural/subdural empyemas were observed in seven cases; three in conjunction with an intracerebral abscess. For reconstruction, free anterolateral thigh fascia lata flaps were used, based on the size of the defect. RESULTS: After removal of the dural substitute and the implant of free fascia lata, infection and CSF leaks resolved in all. An anatomopathological examination of the implant at the later time of cranioplasty (CP) showed the tissue had become vascularized exhibiting integration with the native dura. No complications related to the harvesting of the fascia lata were observed. CONCLUSIONS: Fascia lata is a validated source of autologous grafts; it is cost-free and would appear to be the biological material most similar to the dura mater. The implanted material appears to maintain a lasting vitality when covered over with a well-vascularized scalp, even after a period of months, achieving a successful suppression of infection. Subsequent skull reconstruction is performed safely and easily using artificial bone.

Automated 3D segmentation and diameter measurement of the thoracic aorta on non-contrast enhanced CT.

OBJECTIVES: To develop and evaluate a fully automatic method to measure diameters of the ascending and descending aorta on non-ECG-gated, non-contrast computed tomography (CT) scans. MATERIAL AND METHODS: The method combines multi-atlas registration to obtain seed points, aorta centerline extraction, and an optimal surface segmentation approach to extract the aorta surface around the centerline. From the extracted 3D aorta segmentation, the diameter of the ascending and descending aorta was calculated at cross-sectional slices perpendicular to the extracted centerline, at the level of the pulmonary artery bifurcation, and at 1-cm intervals up to 3 cm above and below this level. Agreement with manual annotations was evaluated by dice similarity coefficient (DSC) for segmentation overlap, mean surface distance (MSD), and intra-class correlation (ICC) of diameters on 100 CT scans from a lung cancer screening trial. Repeatability of the diameter measurements was evaluated on 617 baseline-one year follow-up CT scan pairs. RESULTS: The agreement between manual and automatic segmentations was good with 0.95 ± 0.01 DSC and 0.56 ± 0.08 mm MSD. ICC between the diameters derived from manual and from automatic segmentations was 0.97, with the per-level ICC ranging from 0.87 to 0.94. An ICC of 0.98 for all measurements and per-level ICC ranging from 0.91 to 0.96 were obtained for repeatability. CONCLUSION: This fully automatic method can assess diameters in the thoracic aorta reliably even in non-ECG-gated, non-contrast CT scans. This could be a promising tool to assess aorta dilatation in screening and in clinical practice. KEY POINTS: • Fully automatic method to assess thoracic aorta diameters. • High agreement between fully automatic method and manual segmentations. • Method is suitable for non-ECG-gated CT and can therefore be used in screening.

Anterior cruciate ligament reconstruction in adolescents (Tanner stages 2 and 3).

PURPOSE: Management of anterior cruciate ligament injuries in skeletally immature patients (in Tanner stages 2 and 3) is controversial. Conventional reconstruction used in adults can cause iatrogenic growth disturbance due to physeal damage, and studies that report long-term results using a specific technique are scarce. The aim of this study is to evaluate in a large series the mid- and long-term results of a partial transphyseal technique and define the safe percentage of lesions of the femoral growth plate. METHODS: Between 1989 and 2012, 42 adolescents at risk of growth disturbances (growth prediction of lower limbs >5 cm-Tanner 2, 3) underwent reconstruction of the anterior cruciate ligament using the semitendinosus and gracilis tendons. Growth characteristics of all the patients were assessed preoperatively, and the percentage of damage that would be produced in the femoral physis by the drilling of a 6-mm-diameter tunnel was determined. The technique used achieved graft fixation at both insertion sites, drilling the femoral physis and avoiding the tibial physis. We distinguished two groups: (a) long-term follow-up (mean 13 years 7 months, min 10.9, max 16.2) and (b) medium follow-up (mean 6 years 3 months, min 3.7, max 9.9). All knees were evaluated subjectively by history and objectively by KT2000 testing, and X-rays of both knees were compared for osteoarthritis using the Kellgren-Lawrence classification. RESULTS: In group A (12 patients) one osteoarthritis grade 2, one instability, and ten good stability and function were observed. The mean KT2000 arthrometer values at 30 lb showed a difference of +2.4 mm (range 1-4 mm) between the operated and non-operated sides (p < 0.05). In group B (21 patients) no growth disturbance of the lower limbs, two failures (reinjury while participating in pivoting sports), and 19 good stability and function were observed. The mean KT2000 arthrometer values at 30 lb showed a difference of +1.9 mm (range 1-5 mm) between the operated and non-operated sides (p < 0.05). The average IKDC score of all the patients was 90 (min: 68, max: 97). None of the adolescents had consequences on growth after an eccentric damage passing tendons less than 7% on the frontal plane and of 1% on cross-sectional area of the femoral physis, and after an oblique tunnel passing 6-mm-diameter tendons of the tibial epiphyseal nucleus. CONCLUSIONS: This study defines the possibility to perform a partial transphyseal intra-articular ACL reconstruction in patients in Tanner stages 2 and 3 that avoids tibial physis, involves the distal femoral physis, and produces good results at mid- and long-term follow-up without causing growth disturbances. LEVEL OF EVIDENCE: IV.

Estimation of the prevalence of asymptomatic pancreatic cysts in the population of San Marino.

BACKGROUND: There has been a dramatic increase in the number of pancreatic cystic lesions observed in the past two decades but data regarding the prevalence of cysts in the general population are lacking. METHODS: All the individuals who undergo CT at the San Marino State Hospital are residents of the Republic of San Marino; their demographic distribution is available and precise. CT scans carried out over 1 year at the State Hospital were reviewed for asymptomatic pancreatic cysts. RESULTS: 1061 relevant CT scans were carried out on 814 patients; 762 individuals were eligible for the study and 650 patients underwent contrast-enhanced CT. Thirty-five patients had at least one cyst at contrast-enhanced CT (5.4%). The prevalence of cysts increased with increasing age up to 13.4% (95% CI 6.6-20) in individuals 80-89 years of age (p < .001). Cyst prevalence was significantly higher in patients who underwent CT for malignancy (p = .038) but this difference was no longer significant in multivariate analysis. The odds of a cyst being present increased by 1.05 (95% CI 1.02-1.09) for each increasing year of age (p = .002). Approximately a quarter of the patients with cysts died within 1 year after CT from non pancreas-related disease. The estimated standardized age-adjusted cyst prevalence is 2194 per 100,000 people. CONCLUSIONS: The likelihood of having a pancreatic cyst correlates with increasing age, not with the presence of extra-pancreatic malignancies. The estimated prevalence of CT-detectable asymptomatic pancreatic cysts in the general population is 2.2%.

Lyon bracing in adolescent females with thoracic idiopathic scoliosis: a prospective study based on SRS and SOSORT criteria.

BACKGROUND: The Lyon brace is commonly prescribed in many European countries to patients with thoracic curves and is based on the three-point pressure system. The purpose of this study was to evaluate the efficacy of Lyon bracing for the conservative treatment of adolescent females with idiopathic thoracic curves in a case series selected on the basis of the Scoliosis Research Society (SRS) Committee on Bracing and Nonoperative Management Standardization Criteria and followed the guidelines on management of idiopathic scoliosis with corrective braces, proposed by the International Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT). METHODS: Prospective study based on an ongoing database. From 1297 patients treated for idiopathic scoliosis between 1995 and 2014 fulfill the inclusion criteria 102 patients treated with Lyon brace. Of these, 69 patients had a definite outcome, 17 have abandoned treatment e 16 are still in treatment. The 104 patients were adolescent females with curvatures in the thoracic spine and a pre-treatment Risser score ranging from 0 to 2. All patients were prescribed with full-time Lyon bracing. The minimum duration of follow-up was 24 months after the end of weaning (mean: 41.64 ± 31.45 months). Anteroposterior radiographs were used to estimate the curve magnitude (CM) at 5 time points: beginning of treatment (t1), one year after the beginning of treatment (t2), intermediate time between t1 and t4 (t3), end of weaning (t4), 2-year minimum follow-up from t4 (t5). Three outcomes were distinguished: curve correction, curve stabilization and curve progression. RESULTS: The results from our study showed that of the 69 patients with a definite outcome the CM mean value was 31.51° ± 4.34 SD at t1 and 20° ± 7.6 SD at t5. Curve correction was accomplished in 85.5 % of patients, curve stabilization was obtained in 13 % of patients and curve progression was evident in only 1.5 %. None of the patients were recommended surgery post-bracing. Of 17 patients who abandoned the treatment, at the time of abandonment (14.4 age) have achieved curve correction in 13 cases (77 %), stabilization in 53 cases (18 %) and progression in 1 case (5 %). CONCLUSION: The Lyon brace, through its biomechanical action on vertebral modeling, is highly effective in correcting thoracic curves in particularly when the SOSORT guidelines were adopted in addition to the SRS criteria.

A Clinico-pathologic Study of Oxidized Cellulose as Topical Hemostatic Agent in Neurosurgery.

Hemostasis is extremely important in neurosurgical procedures to prevent major postoperative bleedings and their catastrophic consequences. Emoxicel TAF Retilight (Bioster, a.s., Czech Republic) is a sterile, resorbable, hemostatic reticulum, mainly used to stop capillary and venous bleeding. The textile form of the hemostatic material allows, in several cases, perfect adjustment to the varied shape of the surgical cavities and of the epidural space to which it adheres when wet. Hemostatic effect is rapid, and complete hemostasis can be achieved in several minutes after application. This topical hemostatic agent is biocompatible, biodegradable, and highly resorbable. It has a hemostatic and antimicrobic effect. The main aim of this study was to verify the efficacy, broadness of use, and safety of this topical hemostatic in neurosurgical procedures. A total of 43 cases were included, 18 cranial and 25 spinal, and in only one case a postoperative epidural bleeding was reported. A histopathologic study of the hemostatic was performed. No allergic reactions were reported. Emoxicel was useful not only in stopping minor bleeding, but also for bleeding prevention in the postoperative period.

Weaknesses of histological analysis in celiac disease diagnosis: new possible scenarios.

INTRODUCTION: Celiac disease (CD) is an autoimmune disorder triggered by the ingestion of gluten. Serology and organ culture system can support CD diagnosis, despite histology being the gold standard. AIM: We wanted to test the uniformity of application of Marsh-Oberhuber criteria by five different histologists. We also compared histological and serological data with cultural results to consider new possible strategies in CD diagnosis. METHODS: We studied 114 patients, who were divided in two groups. Group A was composed of 66 patients on a gluten-containing diet, with gluten-related signs and symptoms, showing positive serological anti-endomysial antibodies (EMA) and anti-tissue transglutaminase (anti- tTG). Group B was composed of 48 disease-control patients, presenting serological EMA and anti-tTG negative results. All patients studied underwent esophagogastroduodenoscopy with duodenal biopsy and duodenal mucosa organ culture. All histological samples were evaluated by five different histologists according to an appropriate questionnaire following Marsh-Oberhuber classification. Cohen κ inter-test was used for evaluating the agreement between histologists regarding group A. RESULTS: Strength of agreement was fair/moderate for villous:crypt ratio, moderate/good for villous height and crypt depth, and poor for intraepithelial lymphocytosis. Patients belonging to group A presented positive serological as well as cultural results in 100% of cases. None of the patients belonging to group B presented serological or cultural positive results. DISCUSSION: Our study stresses the limits of histological interpretation due to the lack of uniformity in the use of Marsh-Oberhuber classification. These findings could cast doubt on the role of histology as CD gold standard and could open a debate on the most appropriate CD diagnostic procedure.

Radial neck fractures in children: results when open reduction is indicated.

BACKGROUND: Radial neck fractures in children are rare, representing 5% of all elbow pediatric fractures. Most are minimally displaced or nondisplaced. Severely displaced or angulated radial neck fractures often have poor outcomes, even after open reduction, and case series reported in literature are limited. The aim of the study is to analyze the outcomes of patients with a completely displaced and angulated fracture who underwent open reduction when closed reduction failed. METHODS: Between 2000 and 2009, 195 patients with radial neck fractures were treated in our institute. Twenty-four cases satisfied all the inclusion criteria and were evaluated clinically and radiologically at a mean follow-up of 7 years. At follow-up, the carrying angle in full elbow extension and the range of motion of the elbow and forearm were measured bilaterally. We recorded clinical results as good, fair, or poor according to the range of movement and the presence of pain. Radiographic evaluation documented the size of the radial head, the presence of avascular necrosis, premature physeal closure, and cubitus valgus. RESULTS: Statistical analysis showed that fair and poor results are directly correlated with loss of pronation-supination (P = 0.001), reduction of elbow flexion-extension (P = 0.001), increase of elbow valgus angle (P = 0.002), necrosis of the radial head (P = 0.001), premature physeal closure (P = 0.01), and associated lesions (olecranon fracture with or without dislocation of the elbow) (P = 0.002). DISCUSSION: In our cases, residual radial head deformity due to premature closure of the growth plate and avascular necrosis were correlated with a functional deficit. Associated elbow injury was coupled with a negative prognosis. In our series, about 25% of patients had fair and 20% had poor results. Outcomes were good in 55% and felt to represent a better outcome than if the fracture remained nonanatomically reduced with residual angulation and/or displacement of the radial head. This study reports the largest series of these fractures with a combination of significant angulation and displacement of the fracture requiring open reduction. We feel that open reduction is indicated when the head of the radius is completely displaced and without contact with the rim of the metaphysis.

Non-Small Cell Lung Cancer Testing on Reference Specimens: An Italian Multicenter Experience.

INTRODUCTION: Biomarker testing is mandatory for the clinical management of patients with advanced non-small cell lung cancer (NSCLC). Myriads of technical platforms are now available for biomarker analysis with differences in terms of multiplexing capability, analytical sensitivity, and turnaround time (TAT). We evaluated the technical performance of the diagnostic workflows of 24 representative Italian institutions performing molecular tests on a series of artificial reference specimens built to mimic routine diagnostic samples. METHODS: Sample sets of eight slides from cell blocks of artificial reference specimens harboring exon 19 EGFR (epidermal growth factor receptor) p.E746_AT50del, exon 2 KRAS (Kirsten rat sarcoma viral oncogene homologue) p.G12C, ROS1 (c-ros oncogene 1)-unknown gene fusion, and MET (MET proto-oncogene, receptor tyrosine kinase) Δ exon 14 skipping were distributed to each participating institution. Two independent cell block specimens were validated by the University of Naples Federico II before shipment. Methodological and molecular data from reference specimens were annotated. RESULTS: Overall, a median DNA concentration of 3.3 ng/µL (range 0.1-10.0 ng/µL) and 13.4 ng/µL (range 2.0-45.8 ng/µL) were obtained with automated and manual technical procedures, respectively. RNA concentrations of 5.7 ng/µL (range 0.2-11.9 ng/µL) and 9.3 ng/µL (range 0.5-18.0 ng/µL) were also detected. KRAS exon 2 p.G12C, EGFR exon 19 p.E736_A750del hotspot mutations, and ROS1 aberrant transcripts were identified in all tested cases, whereas 15 out of 16 (93.7%) centers detected MET exon 14 skipping mutation. CONCLUSIONS: Optimized technical workflows are crucial in the decision-making strategy of patients with NSCLC. Artificial reference specimens enable optimization of diagnostic workflows for predictive molecular analysis in routine clinical practice.

A Non-Linear Body Machine Interface for Controlling Assistive Robotic Arms.

OBJECTIVE: Body machine interfaces (BoMIs) enable individuals with paralysis to achieve a greater measure of independence in daily activities by assisting the control of devices such as robotic manipulators. The first BoMIs relied on Principal Component Analysis (PCA) to extract a lower dimensional control space from information in voluntary movement signals. Despite its widespread use, PCA might not be suited for controlling devices with a large number of degrees of freedom, as because of PCs' orthonormality the variance explained by successive components drops sharply after the first. METHODS: Here, we propose an alternative BoMI based on non-linear autoencoder (AE) networks that mapped arm kinematic signals into joint angles of a 4D virtual robotic manipulator. First, we performed a validation procedure that aimed at selecting an AE structure that would allow to distribute the input variance uniformly across the dimensions of the control space. Then, we assessed the users' proficiency practicing a 3D reaching task by operating the robot with the validated AE. RESULTS: All participants managed to acquire an adequate level of skill when operating the 4D robot. Moreover, they retained the performance across two non-consecutive days of training. CONCLUSION: While providing users with a fully continuous control of the robot, the entirely unsupervised nature of our approach makes it ideal for applications in a clinical context since it can be tailored to each user's residual movements. SIGNIFICANCE: We consider these findings as supporting a future implementation of our interface as an assistive tool for people with motor impairments.

Long-term outcome after brace treatment of Scheuermann's kyphosis: an observational controlled cohort study.

BACKGROUND: In the literature, there are several papers on Scheuermann's kyphosis. It is a structural deformity of the spine that is characterized by anterior wedging of 5° or more of 3 adjacent thoracic vertebral bodies with kyphosis measuring greater than 45° between T5 and T12. Bracing treatment is able to obtain, during skeletal growth, remodeling of the deformed vertebrae. AIM: The aim of this study was to evaluate the effectiveness of conservative treatment in Scheuermann's kyphosis at a minimum follow-up of 10 years. DESIGN: This is an observational controlled cohort study nested in a prospective clinical on-going database in patients with Scheuermann kyphosis. SETTING: Inpatients and outpatients in Rome. METHODS: From a consecutive series of patients included in a prospective database, we selected 158 patients with thoracic Scheuermann's kyphosis who were treated using an anti-gravity brace: 93 males and 65 females. The mean age at the beginning of the treatment was 14 years. The time bracing prescribed was a max of 20 hours daily and a min of 16 hours daily. Weaning was started when a full recovery of vertebral geometry was seen on a lateral radiograph view or when growing was ended. Radiographical measurements were performed on radiographs from a lateral projection at baseline (t1), at the end of the treatment (t2) and at 10 years of minimum follow-up (t3). To avoid the great variance in the range of curve angles in thoracic kyphosis (TK) that rely on the radiological position, X-rays were performed observing the following position: standing with head straight, arms bent at 45° and hands lightly placed on a support. The anterior wedging angle (Alpha) of the apex vertebra and the degrees of the curve (Cobb methods) were analyzed using statistical analysis. RESULTS: The results from our study showed that in 158 patients with TK curves, the mean Cobb angle was 57.6±6.3 SD at baseline, 43.3±7.8 SD at the end of treatment and 44.49±7.4 SD at ten years of follow-up. The alpha angle was 14.43±2.535 SD at baseline and 8.571±3.589 SD at the end of treatment, and after ten years of follow-up, it was 8.654±3.57 SD. The mean duration of treatment was 28.42±12.07 months, and the mean follow-up was 128.3±11.07 months. The difference between baseline and end of treatment, tested with the one-way ANOVA comparisons test, was significant (P<0.0001) for both Cobb angle and alpha; instead, the difference between the end of treatment and follow-up was not significant (P=0.3277). CONCLUSIONS: The results confirm that conservative treatment in Scheuermann's kyphosis during skeletal growth is effective. Bracing treatment can remodel the deformed vertebrae. CLINICAL REHABILITATION IMPACT: At the 10-year follow-up after bracing, kyphosis curve correction was stable over time.

Is Surface Topography Useful in the Diagnosis of Scoliosis? Validation of the Biometrical Holistic of Human Body (BHOHB).

BACKGROUND: The concern around repeated exposure to X-rays has been motivating doctors involved in scoliosis to seek alternative solutions. Surface topography (ST) analysis is a modern system that has been shown to have good results. The purpose of the study is to validate the new BHOHB hardware for the investigation of scoliosis in adolescents by comparing it to X-ray examinations and to assess the reliability of intraoperator and interoperator tests. METHODS: Ninety-five patients were enrolled in our study. All the patients were analyzed via the BHOHB method 2 times by 2 independent physicians (t0) and for a second time 2 or 3 months later (t1). The Pearson correlation coefficient was used to evaluate the relationship between the measurements obtained by BHOHB and the gold standard. The intraclass correlation coefficient (ICC) was used to assess intra- and interoperator reliability. Statistical analysis was performed with the GraphPad Prism 8 software. RESULTS: The correlations between the first and second operators in the measurements and between the BHOHB method and X-ray showed a very good to excellent r for both. A very good correlation was also confirmed for prominence measured by operators and by the BHOHB machine. Intra- and interoperator reliability was found to be very positive for both the first and the second physicians. CONCLUSIONS: We can state that ST can be useful for diagnosing and treating scoliosis. The recommendation is to use it primarily to evaluate the evolution of the curve, as in this mode, you can reduce the patient's exposure to X-rays. The results indicate that BHOHB measures are comparable to radiographs and not influenced by the operator.

Anterolateral congenital tibial bowing: case report.

Background: The treatment of congenital curvatures (bowing) of the tibia still represents a challenging problem for all pediatric orthopedic surgeons because of its unpredictable course, especially if pseudoarthrosis occurs after a pathologic fracture of the tibia. Case presentation: We describe the case of a child affected by an isolated curvature of his left leg. The congenital malformation was discovered at birth and no other pathological clinical finding was present. The first x-ray showed the presence of a congenital curvature of the tibia of the antero-lateral type. He was born in another country (Romania) and when he first came to our clinical observation at the Orthopedic and Traumatology Department, Pediatric Hospital "Bambino Gesu'", Rome, the child was 14 months of age and had already started walking. Only a leg discrepancy of about 2 cm was present with consequent pelvis obliquity. At the beginning, we prescribed external lower limb orthoses and a simple shoe rise to prevent a tibial pathologic fracture and reduce pelvic obliquity. At periodical clinical follow-up visits and despite the external lower limb orthoses prescribed, a progressive worsening of the severe congenital tibial curvature was observed together with signs and symptoms, such as pain and limping, that suggested an objective "pre-fracture stage" of the tibial curvature; we decided to perform surgery. At the time of surgery, the child was three and a half years old. Surgery consisted of a double osteotomy, both of the fibula and of the tibia. Subtraction of the distal meta-diaphyseal portion of the fibula and tibial osteotomy in Correspondence: of the major anterolateral curvature. The tibial osteotomy was then stabilized by an internal Rush rod inserted proximally to the tibia under the cartilage growth plate and made it end inside the distal tibial epiphysis, crossing the distal tibial cartilage growth plate, preserving the ankle joint. Results: The patient had an immediately excellent outcome. The tibial osteotomy site healed perfectly. At periodical orthopedic follow-up visits, the child was found to be always better. No clinical significative evidence of growth disturbances, due to the Rush rod that crossed the distal tibial cartilage growth plate, were noted. X-rays showed that the Rush rod progressively migrated with tibial growth together with the tibial bone growth, always getting further away from the distal tibial cartilage growth plate. Moreover, even the leg-length discrepancy and the pelvic obliquity improved. After an eight-year follow up, the patient, now a young boy of 11 and a half years, has an excellent outcome. Conclusions: Our case report undoubtedly provides further important information for the treatment of these rare congenital disorders. In particular, it highlights the management of the "pre-fracture stage" in a severe congenital tibial antero-lateral curvature in a very young child and describes the surgical technique performed.

Management of Open Pediatric Fractures: Proposal of a New Multidisciplinary Algorithm.

BACKGROUND: An algorithm for managing open fractures in children is still being debated; the present study suggests an evidence-based way to manage these patients in the emergency department. METHODS: The literature on "Open fractures in children" was carefully analyzed using keywords. The primary sources were The Cochrane Library, PubMed, and Researchgate. CONCLUSION: We proposed an evidence-based algorithm for managing open fractures in children to standardize clinical practice and improve the care of these patients.

Ray-based approach to skeletal muscle perfusion measurement on interventional x-ray systems.

PURPOSE: Periprocedural assessment of tissue perfusion by imaging methods could improve outcome control during treatment of peripheral vascular disease. Currently, endovascular revascularization treatments are assessed by planar angiography which only allows for qualitative inspection of blood flow in vessels. In this paper, we present a method for periprocedural perfusion estimation based on temporal attenuation curves in skeletal muscles using angiographic C-arm systems. METHODS: The proposed method tackles the loss of spatial depth information which occurs in conventional angiography by combining the acquired angiograms with two additional C-arm rotational soft tissue scans. The area subject to contrast propagation is segmented from the two images that are tomographically reconstructed from the rotational scans and is then used to estimate the spatially averaged temporal contrast attenuation along the x-ray directions from the angiograms. A segmentation method which is tailored to the estimation procedure is applied to limit inaccuracies in the estimation. The accuracy of the method in estimating tissue blood flow in muscular tissue is evaluated in a simulation study using experimental data from CT perfusion acquisitions. RESULTS: Results show that perfusion estimation accuracy is limited owing to spatial inhomogeneity of contrast in muscular tissue and to the presence of vessels along the x-ray directions. Nonetheless, the spatially averaged perfusion quantification allows for improved visual differentiation of normal and hypoperfused tissue in comparison with conventional digital subtraction angiography. CONCLUSIONS: Periprocedural assessment of muscle perfusion through digital subtraction angiography is challenging due to lack of longitudinal information in the planar projections. By including additional 3D information on the anatomy retrieved from rotational soft tissue scans, the visualization and differentiation of normal and hypoperfused areas can be improved.

Patellar dislocation in skeletally immature patients: semitendinosous and gracilis augmentation for combined medial patellofemoral and medial patellotibial ligament reconstruction.

PURPOSE: Patellar instability is a frequent condition in children and adolescents. The problem can be associated with malalignment resulting from different anatomical abnormalities. Several surgical procedures have been suggested for recurrent patellar dislocation consequent to failed conservative treatment. METHODS: We present an original surgical procedure for reconstructing both the medial patellofemoral (MPFL) and medial patellotibial ligaments (MPTL) by semitendinosus (ST) tendon with gracilis (G) autograft augmentation in skeletally immature patients with recurrent patellar dislocation. RESULTS: This technique is effective and permits satisfactory patellar congruency documented by static and dynamic CT. CONCLUSIONS: The operation is associated with optimal functional results and is minimally invasive, causing no growth disturbance. LEVEL OF EVIDENCE: Expert opinion, Level V.

Galeazzi's modified technique for recurrent patella dislocation in skeletally immature patients.

BACKGROUND: A large number of surgical techniques have been proposed for the treatment of recurrent patellar dislocation in adolescents, one of the most famous being Galeazzi's semitendinosus tenodesis as modified by Baker. The aim of this study was to verify the mid-term results of this technique, the effectiveness of restoring the patellofemoral congruency, by both static and dynamic computed tomography (CT), and to determine whether the preoperative type of patellofemoral relationship affects the results. METHODS: The study included 14 patients (16 knees), with a mean age of 11.6 years, Tanner stage ≤3, with at least two to three episodes of patellar dislocation. The patients underwent surgery using Baker's modification of Galeazzi's technique. All 14 patients were evaluated preoperatively and at least 4 years afterward by static and dynamic CT. Clinical evaluation at follow-up was performed using the criteria described by Crosby and Insall. RESULTS: Clinical results at follow-up were excellent in 62.5% and good in 37.5%. As preoperative evaluation showed a high patella in 7 out of 16 knees, two groups were considered: A, high patella; B, not high patella. The data obtained with static CT show that the patella reached a satisfactory congruence in all knees. The data obtained with dynamic CT showed different results between group A and B. A preoperative high patella remains high with quadriceps contraction and again shows the change of tilt and subluxation. In group B, the data obtained with dynamic CT are comparable with those obtained with static CT. CONCLUSIONS: This technique produces good mid-term clinical results. However, the dynamic CT showed that in those patients with high patellas, semitendinosus tenodesis alone is not enough to stabilize the patella.