A great enigma of the Italian Renaissance: paleopathological study on the death of Giovanni dalle Bande Nere (1498-1526) and historical relevance of a leg amputation.

BACKGROUND: The Medici project consisted in archeological and paleopathological researches on some members of the great dynasty of the Italian Renaissance. The remains of Giovanni de' Medici, so-called "dalle Bande Nere" (Forlì 1498- Mantua 1526) have not been investigated yet. The enigma of the fatal injury and leg amputation of the famous Captain excited curiosity of paleopathologists, medical scientists and Italian Society of Orthopedic and Traumatology which contributed to realize the project of exhumation and study of his skeletal remains. The aim of the study is to report the first anthropological and paleopathological results. CASE PRESENTATION: The tomb of Giovanni and his wife Maria Salviati was explored and the skeletal remains were investigated. Anthropological and paleopathological examination defined: age at death, physical constitution and activity, skeletal diseases. The bones of the leg were studied macroscopically, under stereoscopic microscope, at X-ray and CT scans to detect type of injury and level of amputation. CONCLUSIONS: The skeleton and muscular insertions of Giovanni revealed a young-adult and vigorous man, subjected to stresses of military activity since adolescence. Right tibia was amputated below the proximal half of diaphysis leaving long tibio-fibular stumps with a horizontal cut only at the lateral portion. Thus, the surgeon limited to complete the traumatic hemi-amputation. Amputation in the Sixteenth Century technically consisted in guillotine incisions below the knee using crescent shaped knife and bony saw, usually leaving a quite long tibial stump. Amputations in the Sixteenth Century were contaminated and grossly performed not providing vascular binding nor wound closure. The surgeon performed the procedure in conformity with surgical knowledge of that period.

A minimum of 10-year follow-up of the Burch-Schneider cage and bulk allografts for the revision of pelvic discontinuity.

Eighteen consecutive hips with pelvic discontinuity and associated periprosthetic bone deficiency were treated with bulk allografts and Burch-Schneider antiprotrusio cage. Clinical and radiographic follow-up was performed at an average of 13.5 (range, 10.5-16.6) years. Three cages required re-revision because of infection (1) and aseptic loosening (2). Average Harris hip score improved from 31.9 to 77.0 points (P < .001). A severe resorption of the bone graft occurred in 2 hips. The stability of the cage was detected in 13 cases. The cumulative survival rate at 16.6 years with acetabular revision for any reason, radiographic loosening, or unhealing of the discontinuity as the end point was 72.2%. The use of Burch-Schneider cage and bulk allografts is an effective technique for the treatment of pelvic discontinuity.

Percutaneous Distal Osteotomy of the Fifth Metatarsal for Correction of Bunionette.

INTRODUCTION: Percutaneous distal metaphyseal osteotomy, a subcapital linear osteotomy of the fifth metatarsal performed through a minimally invasive percutaneous approach and stabilized with a single Kirschner wire, without soft-tissue procedures, enables the surgeon to achieve consistently good correction of a fifth metatarsal bunionette deformity. STEP 1 WIRE INSERTION: It is mandatory to place the wire in a parosteal position to allow medial displacement of the metatarsal head at the osteotomy site. STEP 2 SKIN INCISION: Make a short skin incision directly to the bone on the lateral side of the distal metaphysis of the fifth metatarsal. STEP 3 PERIOSTEAL DETACHMENT: Detach the periosteum surrounding the bone at the site of the planned osteotomy with a small scissors inserted percutaneously, dorsally initially and then plantarly. STEP 4 OSTEOTOMY: Perform the osteotomy with a micromotorized Lindemann bone cutter, avoiding damage to the surrounding structures by drilling the lateral cortex first and then the medial cortex, keeping the bone cutter in the same lateral entry hole and its tip inside the medullary canal. STEP 5 CORRECTION: The correction is usually satisfactory when contact between the lateral aspect of the metatarsal head and the medial cortex of the metatarsal neck is achieved in the frontal plane. STEP 6 STABILIZATION: Stabilize the osteotomy site with the 2-mm Kirschner wire, driven distal to proximal into the medullary canal of the fifth metatarsal as far as its base. STEP 7 POSTOPERATIVE CARE: Apply adhesive tape with a plantar, kidney-shaped pad. RESULTS: In our study of this technique24, the American Orthopaedic Foot & Ankle Society (AOFAS) score improved from a mean and standard deviation of 51.9 ± 10.2 points preoperatively to 98.4 ± 2.6 points at the time of final follow-up. In 73% of the feet, there was complete resolution of pain at the fifth metatarsophalangeal joint without any functional limitation (AOFAS score of 100). In 20% of the cases, the AOFAS score was 95 points with some decrease in function and a need to use comfortable shoes. In the remaining 7% of the patients, the AOFAS score was 93 points with mild asymptomatic malalignment. No nonunions or recurrences were observed. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

Lumbar artery injury following posterior spinal instrumentation for scoliosis.

Vascular injuries are uncommon but potentially serious complications of spinal surgery. Lumbar artery lesion complicating posterior spinal instrumentation for scoliosis has been occasionally described. A 39-year-old woman with adult scoliosis was treated with correction and stabilization from T8 to L5 via a midline posterior approach. Transpedicular screws were inserted from levels L1 to L5 on the convex left side and at T11, T12, L4, and L5 on the concavity right side. Pedicle screws were not inserted from L2 to L4 on the right side due to difficulty identifying the pedicle channel with the probe. The instrumentation was completed with 2 hooks at T8 and T5 on the left side and 1 at T7. Five hours postoperatively, the patient suffered a hypotensive attack and her abdomen was distended. Her hemoglobin level was 4.5 g/dL. Hemodynamic stabilization was achieved with emergent therapy, including fluid resuscitation, blood, and plasma transfusion. An urgent contrast-enhanced abdominal computed tomography scan showed a large hematoma at the right retroperitoneum with active extravasation of contrast medium, but the source of bleeding was not detectable because of metallic artifacts. Immediate angiography demonstrated rupture of the third right lumbar artery. Selective microcoil embolization was performed with occlusion of the corresponding branch. The bleeding stopped and hemodynamic parameters were stable. No spinal cord impairment or muscle infarction occurred, and 1-year follow-up was uneventful. Lumbar artery injury should be considered as a complication after posterior spinal surgery for scoliosis and prompt diagnosis and intervention are required. Selective lumbar artery embolization is a safe and effective procedure to stop bleeding in hemodynamically stable patients after fluid resuscitation and blood transfusion.

Percutaneous distal osteotomy of the fifth metatarsal for correction of bunionette.

BACKGROUND: Distal osteotomy of the fifth metatarsal is indicated in the surgical treatment of bunionette and varus deformities of the fifth toe in patients with a valgus deviation of the fifth metatarsal. The aim of this study was to evaluate the results of a subcapital percutaneous osteotomy of the fifth metatarsal in the treatment of this disorder. METHODS: From 1996 to 2006, thirty consecutive percutaneous distal osteotomies of the fifth metatarsal were performed in twenty-one patients for the treatment of a painful prominence of the head of the fifth metatarsal. Combined procedures were performed, including a first metatarsal osteotomy in sixteen feet for hallux valgus treatment and a distal open osteotomy of the second metatarsal for painful dorsal dislocation of the second metatarsophalangeal joint in eight feet. The patients were assessed at a mean of ninety-six months with a radiographic and clinical protocol that made use of the American Orthopaedic Foot & Ankle Society (AOFAS) Lesser Toe Metatarsophalangeal-Interphalangeal Scale. RESULTS: The AOFAS score improved from a mean and standard deviation of 51.9 ± 10.2 points preoperatively to 98.4 ± 2.6 points at the time of final follow-up. In 73% of feet there was complete resolution of pain at the fifth metatarsophalangeal joint without any functional limitation (AOFAS score of 100). In 20% of the cases the AOFAS score was 95 points with some decrease in function and a need to use comfortable shoes. In the remaining 7% of patients the AOFAS score was 93 points with mildly asymptomatic malalignment. No nonunions or recurrences were observed. CONCLUSIONS: The percutaneous procedure described here is a reliable technique to perform a distal transverse osteotomy of the fifth metatarsal to correct a painful varus fifth-toe deformity with prominence of the fifth metatarsal head. The clinical results are comparable with those reported with traditional open techniques, with the advantages of a minimally invasive surgical procedure, substantially shorter operating time, and a reduced risk of complications.

Association between CT imaging at follow-up and clinical outcomes in heel fractures.

The reliability of CT data for calcaneal fractures was evaluated, quantifying five CT parameters and investigating their association with clinical outcomes. Fifty-four intra-articular calcaneal fractures surgically treated were considered. Vertical and longitudinal alignment, calcaneal body height, position of sustentaculum tali and subtalar joint congruity were evaluated at 49 months (27-94) follow-up. Each parameter was then quantified and its association with the clinical outcome assessed by the Maryland Foot Score was evaluated. Better clinical outcomes showed a significant association with vertical/longitudinal realignment and with restoration of the calcaneal height. No significant association emerged with reconstruction of the thalamic joint facet congruity. Three-dimensional reconstruction of the calcaneus, in terms of vertical and longitudinal alignment, restoration of the height of the heel body even irrespective of a perfect joint congruity, seems today to be the main goal of the treatment.

Bone transport and compression-distraction in the treatment of bone loss of the lower limbs.

A clinical series of 17 adult patients operated due to significant by bone loss of the long bones of the lower extremity (3 femurs and 11 tibias), is presented. Their management consisted of 6 bone transports (6 tibias) and 11 compression distraction procedures (3 femurs and 8 tibiae) using monolateral external fixators. Bone loss ranged from 3.9 cm to 14.7 cm. Mean healing time was 301 days with a mean healing index of 45.6 days for cm of lengthening achieved. The clinical and radiological results were excellent in 9, good in 6 and fair in 2 patients according to the utilised criteria of assessment. Consolidation was achieved in all but one patient who developed an aseptic stiff non-union. Two patients developed residual limb-length discrepancy less than 1.5 cm, three tibias ended up with less than 5° of valgus deviation. In two cases the half-pins were re-inserted due to early loosening. In two cases reoperation was needed for late bending of the callus after fixator removal. Three cases of bone transport and 1 case of compression distraction needed bone grafting at the docking site. Bone transport and compression-distraction are effective methods for treating bone loss in the lower extremity. It is suggested that the compression-distraction technique is preferable, since this is associated with a lower incidence of complications than bone transport procedures. The deciding factor, however, is the actual extent of the bone loss.

A preformed temporary antibiotic-loaded cement spacer for the treatment of destructive septic hip arthritis: a case report.

Preformed spacers have proved to be effective in the two-stage revision of infected total hip replacements. In the treatment of septic arthritis of the hip, the use of a temporary device has occasionally been described, but the implantation of a preformed antibiotic-loaded spacer has not yet been reported. A 71-year-old man with a destructive Staphylococcus aureus septic arthritis of the hip joint was admitted to hospital. Given the persistence of local infection regardless of all antibiotics and the worsening of joint damage, an aggressive surgical treatment including early placement of a preformed temporary spacer loaded with antibiotics was performed. Two months later an uncemented total hip replacement was successfully implanted. Two years after surgery the patient had a complete functional recovery with no signs of recurrence. The advantages of a preformed device include an effective and predictable local release of antibiotics and a mechanically tested resistance that allows early partial weight bearing and immediate joint mobilization.

Six-year follow-up of a preformed spacer for the management of chronically infected total hip arthroplasty.

Antibiotic-loaded cement spacers are currently used in two-stage revision of septic total hip arthroplasty as temporary devices. Prolonged spacer implantation in infected shoulder has been described occasionally in poor candidates for reconstruction surgery (medically compromised and/or low-physical demand patients, deficient bone stock). Few papers previously reported the use of spacers in infected hip prosthesis as a permanent solution, but limited information is available on the medium-term behaviour. We detail medium-term clinical and radiographic follow-up of a preformed spacer in the management of a chronically infected hip arthroplasty in a 50-year-old female patient who did not undergo a second-stage surgery. Normalization of inflammatory markers was detected 3 weeks after surgery and persisted over time. Six years after surgery, the patient recovered a good range of motion and was able to walk pain free with assisted weightbearing. Remarkable radiological changes of the bone stock around the spacer stem have been assessed. New bone formation developed rapidly in the femur, leading to the consolidation of transfemoral osteotomy 6 months postoperatively. Two years after implantation, spontaneous and asymptomatic fatigue fracture in the mid-part of the stem occurred. Radiographs at 6 years showed a sufficient preservation of bone stock, though a slowly progressive resorption of the cortical femur around the stem was evident in the last year. In conclusion, prolonged spacer implantation seems to be not appropriate in septic hip arthroplasty as a permanent solution. In patients not undergoing a second-stage surgery, a careful and periodic monitoring is required to rule out possible and severe complications.

Stem modularity alone is not effective in reducing dislocation rate in hip revision surgery.

BACKGROUND: Dislocation is a serious complication following total hip arthroplasty (THA). Femoral revision using monoblock components has been associated with high incidence of subsidence and dislocation. Advantages of modular stems in THA have long been debated. The aim of this retrospective study is to assess the capability of an uncemented modular stem in decreasing the incidence of early dislocation subsequent to revision THA. MATERIALS AND METHODS: We evaluated the dislocation rate during the first 2 years following revision surgery in two groups of patients who were treated by implantation of a cementless tapered femoral prosthesis; a standard-modularity stem (Wagner SL) and an increased-modularity stem (Profemur R) were used, respectively, in 66 hips (group I, 64 patients) and 102 hips (group II, 97 patients). Group I consisted of 47 females and 17 males with average age of 66 years (range 29-84 years). Group II included 60 females and 37 males with average age of 70 years (range 48-89 years). RESULTS: Dislocation occurred in six hips (9.1%) of group I and in seven hips (6.8%) of group II (P = 0.401). Dislocations were observed early in both groups, except one hip in group II that dislocated 434 days postoperatively and required surgical reduction. All other dislocations were treated by closed reduction. No recurrence was observed. CONCLUSIONS: The use of an increased-modularity revision stem alone did not prove to be effective in reducing the risk of postoperative dislocation.

Hip resurfacing using the anterolateral Watson-Jones approach in the supine position.

Hip resurfacing is commonly performed using a posterior approach, although some authors have advocated damage to the vascular supply due to posterolateral capsulectomy as one of the possible causes of femoral neck fracture. The need to preserve blood supply has led to the use of an alternative surgical vascular-sparing procedure. This article describes early clinical and radiological outcomes of hip resurfacing via an anterolateral Watson-Jones approach in the supine position. Twenty-eight hips in 26 patients with degenerative hip disease were evaluated retrospectively with a mean follow-up of 28 months (range, 12-61 months). The mean age at surgery was 58 years (range, 26-72 years). The average Harris Hip Score increased from 60 points preoperatively (range, 30-69 points) to 96 points at latest follow-up (range, 80-100 points). Complications included femoral neurapraxia and deep vein thrombosis in 1 patient, which both resolved. One hip required revision due to acetabular cup loosening 15 months postoperatively. No progressive radiolucencies, avascular necroses, or dislocations were observed. Heterotopic ossifications were detected in 3 hips. The absence of early femoral failures in our series may be related to careful patient selection and a proper surgical technique. The anterolateral Watson-Jones approach in the supine position provides optimal exposure of the acetabulum and proximal femur, but a wide soft tissue release is always necessary. We preserve the posterolateral neck capsule to improve the chances of maintaining the blood supply to the femoral neck, even if no differences in clinical outcomes and complications are evident between the anterolateral and posterolateral approaches.

Late fracture of a Burch-Schneider acetabular cage: rare occurrence following polyethylene cup wear.

We report a case of a 46-year-old male patient who sustained a fracture of the Burch-Schneider anti-protrusio cage (APC) that was implanted 13 years before. The fracture occurred in the transitional area to the proximal flange and was caused by direct and recurrent contact between the prosthetic metal head and the acetabular device. Late failure was related to increased wear of the polyethylene cup further aggravated by vertical orientation of the cage. Revision surgery included acetabular reconstruction using a new APC and cross-linked polyethylene cup, and replacement of the 36 mm diameter ball head. At 18 months follow-up the patient showed a complete functional recovery. When a reconstruction device is used, particularly in a young patient, special attention should be paid to the correct positioning of the cage in order to prevent accelerated polyethylene wear. Furthermore, cross-linked polyethylene cups that have become available in recent years must be used.

Bilateral luxatio erecta humeri associated with a unilateral brachial plexus and bilateral rotator cuff injuries: a case report.

Luxatio erecta humeri is an uncommon condition, and only 16 previous bilateral cases have been reported. We present a case of bilateral luxatio erecta humeri associated with unilateral brachial plexus injury and concomitant bilateral rotator cuff tear treated nonoperatively. Seven months after trauma the patient had a good recovery and was able to perform routine daily activities.

Long-term results of anti-protrusion cage and massive allografts for the management of periprosthetic acetabular bone loss.

From 1992 to 1995, 71 total hip arthroplasties with extensive acetabular bone loss underwent revision using bulk allografts and Burch-Schneider anti-protrusion cages. Twelve patients died of unrelated causes and 3 were lost to follow-up. Fifty-six hips were available for clinical and radiographic follow-up examination at an average of 11.7 years after surgery. The average final Harris hip score was 75. X-ray signs of incorporation of massive bone graft were observed in 49 hips. Two cases developed deep infection that required resection arthroplasty. Aseptic loosening of the acetabular cage occurred in 5 patients, and 2 of them underwent re-revision. With a total survival rate of 87.5%, anti-protrusion cages and structural allografts compare favorably with other techniques in the long-term reconstructive treatment of extensive loss of acetabular bone stock.

Minimally invasive retrocapital osteotomy of the first metatarsal in hallux valgus deformity.

OBJECTIVE: Percutaneous retrocapital distal osteotomy of the first metatarsal for surgical treatment of hallux valgus. INDICATIONS: Mild to moderate hallux valgus deformity in both juveniles and adults. Recurrent hallux valgus deformity after previous surgery. CONTRAINDICATIONS: Severe degenerative changes of the first metatarsophalangeal joint (hallux valgus et rigidus). Previous Keller's procedure. SURGICAL TECHNIQUE: A percutaneous distal linear osteotomy of the first metatarsal is performed and stabilized with a Kirschner wire. The surgical technique follows these steps: distal Kirschner wire insertion; skin incision; sparse periosteal detachment; distal retrocapital osteotomy of the first metatarsal; correction of the first intermetatarsal angle by lateral displacement of the capital fragment; stabilization with Kischner wire insertion into the proximal metatarsal; postoperative taping. RESULTS: The patients were satisfied following 107 (91%) of 118 consecutive percutaneous procedures with a follow-up of 35.9 months (range 24-78 months). According to the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale for the clinical assessment, a mean score of 88.2 +/- 12.9 was obtained at follow-up. The clinical results can be compared to those obtained with open techniques, with the advantages of a minimally invasive procedure.

Preoperative autologous blood donation in primary total knee arthroplasty: critical review of current indications.

Preoperative autologous blood donation (PABD) is a well established transfusion practice in elective orthopaedic surgery, involving immunologic and infective advantages but also involving exposure to not negligible risks, and costs as well. The aim of this study was to assess the real need for blood transfusions in primary total knee arthroplasty (TKA). Between January 2000 and July 2005, 214 patients underwent primary unilateral TKA. Altogether, 416 autologous blood units were collected, however only 47 (11.3%) were transfused. Thirty-eight patients (17.8%) received autologous blood, while 4 of them (10.5%) also received allogeneic blood. Based on the results of this study, PABD should be recommended in well selected patients undergoing TKA: older female patients with a low basal haemoglobin level.

Delayed diagnosis of low-symptomatic ceramic acetabular liner fracture in ceramic-on-ceramic total hip arthroplasty.

Alumina ceramics in total hip arthroplasty (THA) have been used in Europe since 1970. Over the years, ceramic-on-ceramic coupling became a valid option in THA because of excellent biocompatibility and tribological properties. The major disadvantages are possible squeaking and risk of breakage, usually disclosed by pain and functional impairment. Squeaking is an audible noise arising from ceramic-on-ceramic bearings, the incidence of which is reported to range from 1% to 7% of THAs. Component positioning, stripe wear, and edge loading have all been implicated. Clicking sounds and scratching have also been anecdotally described. Breakage of a ceramic component due to brittleness of the material is a rare complication. Trauma, high activity level, and obesity may increase the risk of fracture. Defective ceramic manufacture, inadequate implant design, and errors in surgical technique may contribute to breakage. Asian population lifestyle, including squatting, kneeling, and sitting cross-legged, has been correlated to liner rim impingement and fracture. Additional reports concerning failure of various ceramic liners have recently been described.