Autologous chondrocyte transplantation in the treatment of thumb CMC joint osteoarthritis.

Degenerative thumb carpometacarpal (CMC) joint osteoarthritis is a common disease in women starting at 40-50 years of age. Nevertheless, synovitis and initial cartilage damage start earlier, and then degenerative arthritis develops leading to joint narrowing with progressive exposure of subchondral bone, subluxation, osteophyte formation and joint deformity that can impact the surrounding joints. The aim of this study was to evaluate the outcome of patients treated with autologous chondrocyte transplantation at the thumb CMC joint at early stages. A prospective study on 10 cases of thumb CMC osteoarthritis in 8 patients was done. The thumbs were stage Eaton II (2 cases) and III (8 cases) and were treated by CMC arthroplasty with the implant of autologous chondrocytes by an open or arthroscopic technique. Two patients were treated bilaterally. Preoperatively all patients had persistent pain resistant to various kinds of nonoperative treatments for at least 1 year. Mean preoperative pinch strength was 3.7 Kg pain on VAS was 8, DASH was 55. All patients had limited abduction and flexion at the end range. Ethics committee approval was obtained for this study. Fragments of 3-4 mm of cartilage were harvested by arthroscopy or by an open technique from the wrist or elbow joint. Cartilage cells were sent to the laboratory to be grown on a collagenous biphasic matrix (MACI/Novocart®). After 3 weeks, the chondrocyte augmented scaffold was ready to be implanted in the thumb CMC joint, or frozen for a second operation later. All patients were females aged 42-67 years (mean 52 years). The dominant hand was treated in 6 cases. In 7 cases, the patients were operated with an open technique and in three cases by arthroscopy. Partial trapezium resection and dorsoradial ligament reconstruction was added to stabilize the CMC joint in most cases. Patients were seen in person at 1, 3, and 6, months, 1 year, 2 years, and 5 years after the initial surgery. Patients (nine thumbs) were then reviewed at a mean follow up 8 years (range 4.4-11 years); pain on VAS, Mayo, DASH and PRWE scores were evaluated at follow-up. One patient was lost to follow-up after 2 years. Of those nine hands, seven had an excellent result according to Mayo score, one had a good result. One thumb CMC joint was still painful and was reoperated and converted to arthroplasty after 4.4 years. All patients regained full range of motion. Mean pinch strength increased to 6.25 ± 1.3 Kg, mean DASH score was 7.3 ± 6.7; pain on VAS was 1.0 ± 1.5; these data were statistically significant compared to preoperative values (p < 0.01). Grip strength also increased in all cases, but this was not statistically significant. PRWE was 7.7 ± 6.4. No complications occurred postoperatively. The results obtained are encouraging since the implanted cartilage has lasted a mean of 8 years and up to 11 years. Biological tissue engineering techniques are being developed and could be a new solution to restore normal cartilage in young patients to postpone more aggressive surgical procedures until an older age. In cases of CMC joint instability, a ligament stabilization procedure was added to avoid subsequent damage to the implanted neocartilage. A longer follow-up and a greater number of cases are necessary to definitively establish the usefulness of this procedure, which has the advantage of being completely biological but the disadvantage of being costly.

Italian Society for Rheumatology recommendations for the management of hand osteoarthritis.

Hand osteoarthritis (OA) is a common and potentially disabling disease, with different features from hip and knee OA so that a specific therapeutic approach is required. Evidence based recommendations for the management of hand OA were developed by the European League Against Rheumatism (EULAR) in 2006. The Italian Society for Rheumatology (SIR) aimed to update, adapt to national contest and disseminate the EULAR recommendations for the management of hand OA. The multidisciplinary group of experts included specialists involved in the management of patients with hand OA. In order to maintain consistency with EULAR recommendations, a similar methodology was utilized by the Italian group. The original propositions were reformulated in terms of a search query and for every recommendation a systematic search was conducted updating EULAR recommendations' review. The propositions were translated in Italian and reformulated basing on collected evidences and expert opinion. The strength of recommendation was measured for each proposition with the EULAR ordinal and visual analogue scales. The original 11 propositions of EULAR recommendations were translated and adapted to Italian context. Further evidences were collected about non-pharmacological therapies, local treatments, intra-articular injection with SYSADOA and corticosteroids, and surgery. The SIR has developed updated recommendations for the management of hand OA adapted to the Italian healthcare system. Their implementation in clinical practice is expected to improve the management of patients with hand OA.

5-year results of cisplatin-epirubicin-vinorelbine (PEV) combination as primary chemotherapy in T2-3, N0-2 breast cancer patients: a multicentre phase II study.

UNLABELLED: The aim this study was to assess the efficacy of cisplatin-epirubicin-vinorelbine, as primary chemotherapy, in reducing the tumour burden in T2-3 N0-2 breast carcinomas. Breast conservative surgery (BCS) rate, clinical and pathological complete response (pCR), toxicity and 5-year disease-free survival (DFS) and overall survival (OS) were evaluated. PATIENTS AND METHODS: Eighty-eight women with tumours > or =2.5 cm were treated with cisplatin (P) 50 mg/m2, epirubicin (E) 100 mg/m2 and vinorelbine (V) 25 mg/m2, every 3 weeks. RESULTS: Fifty-six out of the 88 patients (63.6%) underwent BCS, notably including 12/23 patients with initial tumours >5 cm. The overall clinical response was 72.8% (cCR=11.4%), pCR 20.5% and pTO+pNO 17%. No cardiac toxicity was observed. Grade 3/4 adverse events were leukopenia (9.4%), neutropenia (7.9%), nausea and vomiting (7.3%). After a median follow-up of 5 years, 24 patients (27.3%) had developed local or distant metastases. The mean DFS and OS were 51.7 (SE 2.38) and 57.02 (SE 1.98) months, respectively, and were significantly higher in pCR patients in comparison to the others (63.05 vs. 48.76, p<0.01 and 64.59 vs. 55.04, p<0.05, respectively). CONCLUSION: The PEV regimen was highly effective in reducing the tumour burden, especially for large tumours. The rate of pCR was similar to that obtained by other, including taxane-based regimens, and was well-tolerated. The study demonstrated the feasibility of such a regimen even in small centres, and being of low cost this combination could be of value in the application of primary therapy.

PCR testing for HCV in anti-HCV negative blood donors involved in the so called HCV +ve post-transfusion hepatitis.

UNLABELLED: Although it is infrequent, post-transfusion HCV infection may occur if the donors blood is collected in the window period between exposure and anti-HCV detectability by ELISA testing. STUDY DESIGN: In these last years, despite of routine application of anti-HCV testing, our blood transfusion center has been involved in 53 cases of alleged post-transfusion HCV hepatitis and look-back programs were set up with the goal of finding out the donors possibly involved in viral transmission. Most of these patients were hematological cases with multiple transfusions given because of aplastic anemia (3 cases), leukemia with or without bone marrow transplantation (5/4 cases) but necessitating long-term platelet support, leukemia and solid cancer patients undergoing autologous PBSC transplantation (3/4 cases) and TTP (2 cases). Only 32 patients were of the simple medical or surgical type, 9 transfused because of cardiac or vascular surgery, 8 because of spine surgery, 5 for different diseases and 5 for different types of cancer surgery. Donor's infectivity was determined by ELISA anti-HCV testing, by recombinant immunoblotting assay, and by nucleic acid testing. RESULTS AND CONCLUSION: No donors out of 267 traced of a total of 359 involved was found with anti-HCV seroconversion, or positive on PCR testing. This suggests that the responsibility for HCV transmission can only hypothetically be related to blood or blood components and that other transmission routes should be found out.

[Automatic opto-electronic control of patient position in radiotherapy for breast carcinoma]. / Controllo opto-elettronico automatico della posizione del paziente nella radioterapia del carcinoma mammario.

INTRODUCTION: We report on the technical and clinical validation of a system for real-time analytical control of patient position at simulation and treatment units in radiotherapy. MATERIAL AND METHODS: The positioning control system uses a technology for motion analysis consisting of an optical component (a pair of TV cameras) and of a unit for real-time image processing. The system can provide real-time (up to 100 times a second) three-dimensional (3D) coordinates of a set of passive markers (small plastic hemispheres, 5 mm O) previously positioned on the patient and located within the field of view of the system's TV cameras. The method for positioning quality control is based on the analytical comparison between the current positions of the set of markers placed on the patient's skin and a corresponding reference pattern, the latter acquired at the end of the simulation procedure or at the first irradiation session. The system was used at the Radiotherapy Division of the European Institute of Oncology for the analytical control of repositioning in three patients submitted to irradiation after conservative surgery (quadrantectomy) for breast cancer. This showed the clinical feasibility of both the technology and the method, and permitted to quantify improvement in patient positioning relative to current repositioning procedures. In particular, the possibility to evaluate the patient's breathing phases allowed to distinguish the different factors (repositioning inaccuracies and cyclic and random patient movements) contributing to global localization errors. RESULTS: This method is independent of physical and geometrical irradiation parameters and permits efficient real-time quantitative control of specific repositioning quality and of actual patient immobility during irradiation. Assessment of the accuracy of conventional repositioning methods based on laser alignment showed a fair performance of the optical centering procedure (with 3D displacements < 5 mm) only for the markers placed close to the skin landmarks used for laser alignment. On the contrary, the markers within the irradiation field but not directly controlled during the repositioning procedure exhibited localization errors > 5 mm; this happened even though the inaccuracies related to patient's breathing movements had been excluded from analysis. Moreover, quantitative assessment of global localization errors confirmed the high influence of breathing movements on the position repeatability and maintenance. In this case, even the markers which were on average well repositioned turned out to be significantly displaced during the radiation dose delivery. CONCLUSIONS: Our results confirm that real-time motion analysis based on opto-electronic techniques can play a crucial role as a means of improving patient positioning and assessing immobility. Thus, the system permits to quantify errors in target volume localization, which permits to adopt suitable countermeasures to reduce uncertainties during actual irradiation. This is a crucial requirement, particularly when the complexity of the irradiation geometry (conformal radiotherapy) or radiation type (hadrontherapy) calls for optimal application of the simulated treatment plan to each actual irradiation session.

Automatic volumetric capillary cytometry in the routine of an apheresis unit involved in multicomponent collection.

In apheresis, leukodepletion by secondary filtration of the platelet components or by the primary use of special high efficiency apparatuses is widely used to meet current clinical practice. Leukodepletion of RBC is mandatory for hematooncological patients and new filters for plasma are progressively being introduced in the routine of European blood banks. However, since the monitoring of leukodepletion efficiency continues to be carried out manually using the Nageotte or the microdroplet fluorescence assay (MFA), inaccuracy and labour-intensity of counting will limit the possibility of satisfying the increasing demand for leukodepletion monitoring. Volumetric capillary cytometry (VCC) is a totally automated system that has been shown to correlate well with Nageotte, MFA and flow-cytometric countings of residual leukocytes in platelet and RBC product. In this article we describe the application of VCC in the quality control program of our hemapheresis unit in which all apheresis donations are of the multicomponent collection type.

[Relation between L5 sacralization and hernia of the lumbar disk]. / Studio del rapporto fra sacralizzazione di L5 ed ernia del disco lombare.

The AA. present a study on the relationship between the most common congenital malformation of the lumbosacral passage: the sacralization of L5 and lumbar disc hernia. The examination of 200 cases of lumbar disc hernia shows a sacralization incidence of 11.5%.

[Osseous hydatidosis: presentation of a rare localization and review of the bibliography]. / Idatidosi ossea: presentazione di una rara localizzazione e revisione della bibliografia.

The AA. present a rare case of osseus hydatidosis relapsed 27 years after the surgical treatment, located in the tibia and fibula, where the near soft tissue as well as the S.P.E. were involved. A critical revision of the bibliography is presented.

[Review of 41 cases of surgically treated acromioclavicular dislocations]. / Revisione di 41 casi di lussazione acromio-claveare di 3 tipo trattati chirurgicamente.

The authors have examined the follow-up of 41 cases of acromio- clavicular dislocation, treated by internal fixation. Statistics show a very good end result.

[Use of the external fixator in the treatment of recent fractures of the leg]. / Uso del fissatore esterno nel trattamento delle fratture recenti di gamba.

The authors show 30 cases of recent tibial fractures treated by external fixation. They study the different types of fractures, the models of external fixation employed, the complications occurring during the treatment and the ultimate results obtained.

[Evaluation of the aftermath of trimalleolar fractures of the tibio-tarsal joint]. / Valutazione dei postumi delle fratture trimalleolari della tibio-tarsica.

The authors have examined the follow-up of 57 cases of trimalleolar fractures treated by internal fixation. Statistics show a good end result. The Authors, moreover, report the frequent presence of synostosis tibio-fibulare distale. This condition, however, has no influence on ankle motion.

[Frieberg-Kohler disease. Long-term review of the surgical treatment in 20 cases]. / La malattia di Frieberg-Kohler. Revisione a distanza del trattamento chirurgico in 20 casi.

The authors show the reviewing of twenty patients suffering from Frieberg-Kohler's disease, surgically treated from 1975 up to 1980. The surgical intervention had been suggested by the important painful symptomatology, resisting to the conservative therapy. At checking, the patients were all satisfied with the results of operation, and could start again with their usual job.

[Osteochondritis dissecans of the elbow (presentation of 2 rare cases)]. / L'osteocondrite dissecante del gomito (presentazione di due rari casi).

The authors show two cases of dissecting osteochondritis of elbow, confirming the frequent absence of a clinical symptomatology in the initial stages of such disease and the benignancy of its course. From a careful study of the casuistries present in literature, what emerges is the rareness of this location, together with a prudent therapeutical trend with periodic clinical and radiographical checkings, reserving the surgical solution to the cases of articular free body with episodes of block.

[Considerations on the surgical treatment of hallux valgus]. / Considerazioni sul trattamento chirurgico dell'alluce valgo.

The authors, after showing a critical analysis of the most interesting operations for correction of valgus big toe in the history of orthopaedics, show the technique they followed, as well as the results obtained, in a specimen chosen among the patients treated with such method.

[Anatomo-pathologic and therapeutic considerations on the Papineau method]. / Considerazioni anatomo-patologiche e terapeutiche sulla "metodica Papineau".

The authors study the treatment of bone infections through Papineau's technique, and emphasize the element they consider essential in the process restoring the loss of substance: the "bouton" according to the French School. On the basis of the experience deriving from the treatment of 22 patients, they subsequently point out the importance of local antibiotic therapy and, on the contrary, the inefficacy of the administration of antibiotics by general way, at least as far as the not strictly surgical period is concerned.

[Incidence of painful pronation in pediatric traumatology]. / Considerazioni sulla frequenza della pronazione dolorosa nella traumatologia infantile.

After examining the traumatic mechanism responsible for the lesion and considering the possible pathogenetic interpretations, the Authors pass to a description of the clinical picture and the simple but effective reduction manoeuvre. The attached cases tend to emphasize the by no means negligible frequency of painful pronation among childhood traumatisms, a condition often misunderstood and a source of wrong diagnostic interpretations.