RADIAL head arthroplasty: does ligaments repair influence outcomes? A minimum two years follow-up radiographic multi-center study.

PURPOSE: The current indication for comminuted radial head fractures is radial head arthroplasty (RHA). The main purpose of this study was to investigate any statistical differences in terms of prosthesis revision or removal and radiographic degenerative changes by comparing patients who underwent RHA and ligaments repair to those who underwent only RHA implant at minimum two years follow-up. The secondary aim was to delineate a trend profile of RHA implants. METHODS: All patients who underwent RHA surgery for traumatic pathology between January 2012 and December 2017 were eligible. Two researchers independently and retrospectively reviewed the patients' charts and collected the following data: type of prosthesis, associated surgical procedures and revision surgery. They also looked for any radiographic sign of prosthesis loosening, overstuffing, capitellar osteopenia, heterotopic ossification and degenerative changes. No clinical evaluation was performed. RESULTS: In 6 years, 124 RHA were implanted (74 female, 50 male, mean age 56). The main diagnoses were: terrible triad, trans-olecranon fracture and isolated radial head fracture. It was found no significant statistical difference between the 2 groups; nevertheless, the cohort of patients that underwent ligaments repair had a lower revision rate in comparison with the other. Suture of the annular ligament seems to be critical. The overall revision rate was 10.5%. CONCLUSION: This multi-center study found no evidence that ligaments repair, as an associated surgical procedure, improves RHA longevity, except for annular ligament. Nevertheless, it seems to prevent degenerative changes at midterm follow-up.

Point of Care Ultrasound to Identify Diaphragmatic Dysfunction after Thoracic Surgery.

BACKGROUND: Postoperative diaphragmatic dysfunction after thoracic surgery is underestimated due to the lack of reproducible bedside diagnostic methods. We used point of care ultrasound to assess diaphragmatic function bedside in patients undergoing video-assisted thoracoscopic or thoracotomic lung resection. Our main hypothesis was that the thoracoscopic approach may be associated with lower incidence of postoperative diaphragm dysfunction as compared to thoracotomy. Furthermore, we assessed the association between postoperative diaphragmatic dysfunction and postoperative pulmonary complications. METHODS: This was a prospective observational cohort study. Two cohorts of patients were evaluated: those undergoing video-assisted thoracoscopic surgery versus those undergoing thoracotomy. Diaphragmatic dysfunction was defined as a diaphragmatic excursion less than 10 mm. The ultrasound evaluations were carried out before (preoperative) and after (i.e., 2 h and 24 h postoperatively) surgery. The occurrence of postoperative pulmonary complications was assessed up to 7 days after surgery. RESULTS: Among the 75 patients enrolled, the incidence of postoperative diaphragmatic dysfunction at 24 h was higher in the thoracotomy group as compared to video-assisted thoracoscopic surgery group (29 of 35, 83% vs. 22 of 40, 55%, respectively; odds ratio = 3.95 [95% CI, 1.5 to 10.3]; P = 0.005). Patients with diaphragmatic dysfunction on the first day after surgery had higher percentage of postoperative pulmonary complications (odds ratio = 5.5 [95% CI, 1.9 to 16.3]; P = 0.001). Radiologically assessed atelectasis was 46% (16 of 35) in the thoracotomy group versus 13% (5 of 40) in the video-assisted thoracoscopic surgery group (P = 0.040). Univariate logistic regression analysis indicated postoperative diaphragmatic dysfunction as a risk factor for postoperative pulmonary complications (odds ratio = 5.5 [95% CI, 1.9 to 16.3]; P = 0.002). CONCLUSIONS: Point of care ultrasound can be used to evaluate postoperative diaphragmatic function. On the first postoperative day, diaphragmatic dysfunction was less common after video-assisted than after the thoracotomic surgery and is associated with postoperative pulmonary complications.

Hinged external fixation for complex fracture-dislocation of the elbow in elderly people.

The authors report their experience of treating complex elbow fracture-dislocations in elderly people, using a minimally-invasive approach with a new articulated external fixator that is associated with minimal internal fixation. The clinical results for 19 patients are presented according to outcome factors, such as range of motion, pain and function, rate and type of complications, and reoperation rate. The results indicate that this treatment strategy should be considered as a good alternative to other treatment options reported in the literature, including conservative treatment, ORIF with angular stable plates and total elbow arthroplasty.

Percutaneous hallux valgus surgery: strengths and weakness in our clinical experience.

BACKGROUND AND AIM OF THE WORK: The Reverdin-Isham percutaneous osteotomy is indicated in the treatment of mild to moderate hallux valgus deformity. The aim of the work is the evaluation of the technique itself as a possible future landmark in the hallux valgus treatment. METHODS: Between January 2010 and January 2011 we have performed 138 percutaneous osteotomies. The patients were assessed with a clinical and radiological control after a median five months follow up. The score proposed by the American Orthopaedic Foot and Ankle Society was used for the clinical evaluation. RESULTS: The average score has improved from a preoperative median of 45 points to a postoperative median of 91 points. The technique has been largely accepted by the patients because of the speed of the procedure itself, the minimal invasiveness, the short pain and the immediate functional recovery. CONCLUSIONS: The results we have obtained with the Reverdin-Isham procedure have confirmed that this technique is a valid alternative to other percutaneous techniques and open surgical procedures. However the technique is not simple, it needs the strict indications observance and it needs a steep learning curve, those are features that impose further future studies.

Conservative treatment vs prosthetic replacement surgery to treat 3- and 4-fragment fractures of the proximal epiphysis of humerus in the elderly patient.

Several previous studies have revealed a significant difference in the functional results obtained between conservative treatment and prosthetic replacement surgery to treat complex fractures of the proximal end of the humerus. Thus, prosthesis is the gold standard in treatment of such fractures. It is the purpose of this study to analyze the functional results obtained with the conservative treatment of 18 consecutive patients, mean age 78 years, affected with 3- and 4-fragment fractures of the proximal epiphysis of humerus. A comparison of functional results that may be obtained when prosthetic replacement is performed does not show significant differences in this category of patients. Thus, in order to limit complications, when the patient is elderly, complex fracture of the proximal epiphysis of humerus should be treated conservatively.

[Carbon dioxide embolization: is it a complication of laparoscopic cholecystectomy? ]. / Embolia gassosa da biossido di carbonio: è una complicanza della colecistectomia laparoscopica?

The occurrence of pulmonary gas embolism in patients undergoing laparoscopic cholecystectomy is reported in the medical literature. Severe intraoperative complications or the patient's death were correlated to gas embolism during laparoscopic procedures. However, the careful retrospective study or the autoptic exam of such casualties have always showed an erroneus direct puncture of vessels or the straight insertion of the Veress needle into a parenchymal organ. It is obvious that the direct gas injection into a vein or into parenchymal organs is a primary cause of gas embolism, as well as the high flow insufflation of gas into the peritoneal cavity in concomitance with the lesion of major abdominal vessel's wall. Gas embolism may occur each time the vein internal pressure is lower than the external pressure and not only during a laparoscopic procedure when carbon dioxyde is inflated into the peritoneal cavity, but also during open surgery such as major liver resections, neurosurgery, vascular or cardiac surgery. The review of large series of laparoscopic cholecystectomies reported in the international literature, as well as our own clinical experience in this field, together with the results of laboratory animal studies based on the experimental insufflation or injection of carbon dioxyde, show that gas embolism must not be considered as a complication of laparoscopic surgery. Due to the above mentioned risks with the use of the Veress needle, the surgeon should revalue alternative means in creating the pneumoperitoneum.

IMHS clinical experience in the treatment of peritrochanteric fractures. The results of a multicentric Italian study of 981 cases.

This retrospective study evaluates the results obtained in five Italian departments of traumatology in the treatment of peritrochanteric (pertrochanteric and subtrochanteric) fractures by the intramedullary hip screw (IMHS; Smith & Nephew Richards, Memphis, TN, USA) nail. One thousand two hundred and seventy-three patients were treated with the IMHS nail between March 1992 and February 2000. The results of these operations were evaluated clinically and radiological in 981 patients. The 90.3% of patients could walk unaided or with simple support. Because of the low complication rate requiring re-operation (postoperative shaft fractures, screw penetrated the acetabulum, cut out and non-union) (1.7%), we think that this device is an advance in the treatment of peritrochanteric fractures.

Compression hip screw nail-plate system for intertrochanteric fractures.

BACKGROUND: The worldwide increased incidence in fractures of the proximal end of the femur is increasing with the parallel increase in the average age of the population. The advanced age and poor physical condition of these patients render surgery necessary. METHODS: In 1999, at the Orthopaedic Clinic of the University of Siena, 56 patients were treated with the compression hip nail-plate system, a new synthesis device for the treatment of peritrochanteric fractures. The system consists of a new dynamic cephalic screw that could be combined with a plate or a femoral nail. The dynamic cephalic screw of the BCM system has a limited sliding method, impeding excursions greater than 10 mm and preventing excessive collapse of the fracture fragments that can evolve into a shortening of the limb. The canulated nail has a diameter of only 9 mm, which permits insertion into the shaft canal without reaming. RESULTS: Four patients with a follow-up of less than 3 months, 2 patients lost to control, and 1 patient who died were excluded from the study. All 49 remaining patients healed clinically and radiographically within 3 months. CONCLUSIONS: The possibility of the double combination of the screw with a plate or with an intramedullary nail permits the surgeon to have a double solution with a single instrument at hand, and offers the opportunity of changing the choice of synthesis method to implant even during surgery.

Pneumococcal septic arthritis of the shoulder. Case report and literature review.

Septic arthritis due to Streptococcus Pneumoniae appears to be relatively uncommon. Single- or clustered-case histories constitute the majority of reports on pneumococcal septic arthritis. A 70-year-old man presented with a 7-day history of pain, erythema and swelling of the left shoulder. Physical examination of the left shoulder revealed a warm, swollen, erythematous, and markedly tender to light palpation. The patient was unable to elevate his arm more than 30 degrees without pain. Arthrocentesis performed on admission produced 30 cc of grossly purulent fluid whose culture demonstrated S. Pneumoniae. The septic arthritis was treated with intravenous vancomycin and imipenem. The antibiotics were substituted when the sensitivities were known with oral ciprofloxacin and rifampycin to complete 8 weeks' total treatment. On follow-up examination 1 year later, the patient has remained afebrile and asymptomatic without evidence of increasing joint effusion or acute joint inflammation. Pneumococcal arthritis is classically described as a painful monoarticular arthritis complicating an active pneumococcal infection, generally a primary pulmonary infection. Pneumococcal arthritis appears to be predominantly a disease affecting the elderly. Clinical presentation ranges from septicemia to indolent infection with few systemic symptoms. With adequate antibiotic therapy and aspiration or drainage of the joint, the prognosis for return of normal joint function appears to be excellent. Although pneumococcal organisms are not likely causes, this bacteria should certainly be considered as a possible cause of arthritis or prosthetic infection.

Use of a modified IMHS for unstable intertrochanteric fractures.

The treatment of unstable intertrochanteric fractures in elderly osteopenic patients, especially those who cannot follow limited weight bearing instructions, is controversial. Recent publications indicate concern with excessive sliding of telescoping nail or sliding screw devices when used in these unstable intertrochanteric fractures. In our experience with the use of intramedullary hip screw (IMHS) in these fracture patterns, we have observed excessive sliding and collapse of the fracture in some patients. We modified the keyed centering sleeve by threading its internal distal third and substituted the compression screw with a custom bolt to obtain restricted sliding or rigid fixation depending on the gap between the lag screw and custom bolt. We used this modified system in static configuration to treat five patients who had an unstable intertrochanteric fracture of the femur. The length of the involved limb measured at the time of consolidation showed no shortening. In view of these results, intertrochanteric hip fractures that are unstable in patients with poor bone-stock can be fixed using the modified IMHS in a static or controlled sliding configuration.

Domestic preparedness: the grand illusion.

The problems posed by terrorism to not only the emergency response community, but to national security at large can be overwhelming. Adoption of what would be considered prudent and effective business practices by implementing a disciplined and effectively structured central strategy cannot be overencouraged. The emerging strategy must take into account the existing emergency response infrastructures and build upon existing capacity in an effort to achieve greater readiness. This technique is no different than the training and issuance of radiological response equipment to emergency responders in the 1950s by the then Civil Defense Agency. The training that is offered, especially to EMS providers, needs to be institutionalized to ensure that our peers, on a regular basis, revisit curriculum content. Incorporating a training module within the existing DOT NHTSA initial and refresher EMT and paramedic educational curricula could easily achieve this goal. Implementing fiscal support to the local emergency response agencies in a sustainable manner is a must. The costs associated with training, equipping and servicing the equipment and medication stores are budget-busters. This is a threat to national security and, as such, the federal government needs to rise to the challenge of supporting the local response organizations that will meet this threat head-on during the aftermath of an attack. As previously mentioned, when the U.S. faced its last large national security threat (Soviet nuclear missiles), we witnessed the materialization of a comprehensive agenda that provided most of the attributes we desire with the contemporary problem of terrorism. There is no single solution to the problem of terrorism. In fact, it will take many individuals and functional areas to come together and stop viewing the threat as a "cash cow." The improved response capacity for acts of terrorism will have an inevitable "spillover benefit" of better trained and equipped emergency responders for everyday emergencies; which will inevitably be our "payday."

[Osteochondroma. Report of a case with atypical localization and symptomatology]. / Osteocondroma. Presentazione di un caso a localizzazione e sintomatologia atipica.

Osteochondroma, the most common benign bone tumor, represents 10-15% of all bone tumors. It can occur frequently as solitary osteocartilagineous exostosis or rarely as hereditary multiple lesions. The most common sites of occurrence are long bones of the lower arm (50%), usually the lower end of the femur and upper end of the tibia. However, involvement of the small hand and foot bones occurs in 10% of cases, pelvis in 5%, scapulae in 4%, and spine in 2%. Symptoms are not very specific. The authors present an atypical case of osteochondroma.

Preliminary experience with a new osteosynthesis device for intertrochanteric fractures.

From 1999, at the Orthopaedic Clinic of the University of Siena, 56 patients were treated with the compression hip nail-plate system, a new synthesis device for the treatment of peritrochanteric fractures. The system consists in a new dynamic cephalic screw that could be combined with a plate or a femoral nail. The dynamic cephalic screw of the BCM system has a limited sliding method, impeding excursion greater than 10 mm and preventing excessive collapse of the fracture fragments that can evolve into a shortening of the limb. The canulated nail has a diameter of only 9 mm, which permits insertion into the shaft canal without reaming. The possibility of the double combination of the screw with a plate or with an intramedullary nail permits the surgeon to have a double solution with a single instrument at hand, and offers the opportunity of changing the choice of synthesis method to implant even during surgery.