Unusual presentation of recurrent subtrochanteric non-union in a patient with hip arthrodesis: A case report.

This case report describes the management and therapeutic solution for the treatment of subtrochanteric non-union in a patient with hip arthrodesis. Two techniques can be used in the treatment of these non-unions: a closed intramedullary nailing or an open technique with plate, preferably carried out together with cortical bone graft. The surgical technique varies depending on the fixation method used for the initial treatment of the fracture and on the characteristics of the non-union. We report an unusual case of a patient who started her long clinical history more than 40 years ago with a septic arthritis of the hip healed in arthrodesis. 35 years later, after having undergone various surgeries, she fractured the proximal femur, which had to be operated seven times before reaching healing. Satisfactory outcomes were finally obtained. Arthrodesis proved to be the main cause of failed healing and of the recurrent non-union.

Periprosthetic acetabular fractures: A New classification proposal.

INTRODUCTION: Acetabulum periprosthetic fractures are rare, but are increasing, due to increase in high-energy trauma and a decrease in mortality index. Reconstruction of an acetabular fracture, in the presence of hip arthroplasty can be very complex and represents a real challenge for orthopedic surgeon. Aim of this multicentric study is to classify periprosthetic acetabulum fractures and to propose a treatment algorithm. MATERIALS AND METHODS: 24 cases of acetabular periprosthetic fracture were treated surgically from 01.01.2010 to 31.04.2017 in three different hospitals; 4 males and 20 females, average age 76 years (range 56-90 years). TREATMENT: 4 cases treated conservatively, 8 cases ORIF, 2 cases treated with acetabular ring and screws, 9 cases ORIF and acetabular cup revision, 1 implant removal without revision. RESULTS: All cases were reviewed at minimum 12 months follow-up. In 22 cases, there was no need for new surgical procedures and radiographically all implants appeared stable and with good bone integration. In a case of a type 1b fracture, a dislocation of prosthetic implant was observed after 3 months. In a case prosthesis was explanted and it was not possible to perform a revision. DISCUSSION AND CONCLUSIONS: Fracture classification systems must facilitate communication between surgeons and encourage documentation and research. However, they should also have prognostic value, so from them should come directly a treatment algorithm. In our experience, most important factors as prognostic and therapeutic predictors were: implant stability and timing of fracture: intraoperative or postoperative. In postoperative fractures CT is mandatory to evaluate cup mobilization and fracture patterns. Our classification proposal is simple and easy to remember for daily use. From it is derived a simple treatment plan.

Why a surgically treated humeral shaft fracture became a nonunion: review of 11 years in two trauma centers.

AIM: The aim of this study was to evaluate nonunion causes of surgically treated humeral shaft fractures in two different trauma centers. METHODS: A total of 327 cases of humeral shaft fractures were treated in 11 years in two trauma centers. We retrospectively reviewed in detail some factors in order to understand the reasons for nonunion: (1) fracture type, according to the AO classification, (2) grade of open fracture, according to Gustilo-Anderson, (3) timing, (4) reduction and (5) fixation. RESULTS: We observed 19 nonunions, 10 women and 9 men, with an average age of 57 years. Fractures were 1 A1 case, 2 A2 cases, 4 B2 cases, 6 B3 cases, 2 C1 cases, 1 C2 case and 3 C3 cases. Three cases had a simple fracture with two fragments; all the other were comminuted. Fifteen cases were closed, four open. The major criticalities observed were fracture comminution, exposure, unstable fixation and bone resorption. All 19 patients with nonunion underwent surgical fixation with compression plate and frozen cortical bone graft. A 4.5 LCP plate was used in 17 cases. The remaining 2 cases had an anatomical site-specific proximal humeral 3.5-mm LCP plate (Synthes, Paoli, PA, USA). In 17 patients, the nonunion healed: 15 cases treated with a 4.5 straight plate, and 2 cases with an anatomical site-specific proximal humeral 3.5 mm LCP plate, at a mean of 5 months. In 2 cases, consolidation was not reached. CONCLUSIONS: We believe that humeral diaphyseal fractures should be treated surgically to avoid many complications. Our retrospective analysis indicates that factors that lead to a fixation failure are fracture comminution, open fracture, unstable fixation. The 19 nonunions treated with compression plating and frozen bone graft demonstrated consolidation in almost 90% of the cases.

Distal-third diaphyseal fractures of the humerus: choice of approach and surgical treatment.

PURPOSE: Distal-third diaphyseal fractures of the humerus are often hard to treat due to location and pattern of the fractures, radial nerve injury, and quality of bone and age of patients. The aim of this retrospective study is to propose the best approach and the best surgical technique according to the pattern of extra-articular fracture of the distal humerus. METHODS: We have treated 37 fractures of the distal humerus between January 2010 and July 2015 classified according to the AO classification. There were 2 open fractures. We treated all fractures with open reduction and internal fixation with plates and screws. In 20 cases, we performed a posterior midline triceps-splitting approach, with patients in prone decubitus position; in 2 cases, the triceps-splitting approach with the patients in supine decubitus position; in 3 cases, the olecranon osteotomy approach in prone decubitus position; and in 12 cases, the lateral approach in supine decubitus position. RESULTS: Thirty cases had a medium follow-up of 6 months. We observe 2 post-operative radial nerve palsies healed in 5 months and 2 cases of non-union. The average time to union of remaining cases was 16 weeks (range 12-24). Elbow motility was complete in 25 cases, in 4 cases there was an extension loss of 5°, and in one case there was an extension loss of 10°. CONCLUSIONS: The use of plates allows an anatomical fracture reduction, a better control of alignment of humerus and, with a rigid fixation, an early elbow mobilization. The best approach and the best surgical technique depend on the pattern of the fracture of distal humerus.

How evolution of the nailing system improves results and reduces orthopedic complications: more than 2000 cases of trochanteric fractures treated with the Gamma Nail System.

PURPOSE: The incidence of trochanteric fractures has increased significantly during the last few decades, especially in elderly patients with osteoporosis. The dynamic/sliding hip screw and the cephalomedullary nail are the most commonly used fixation methods to treat trochanteric fractures. The improvements in the Gamma Nail System (GNS) associated with a correct surgical technique reduced the postoperative orthopedic complications. The purpose of this study was to compare the results of the different Gamma Nails. METHODS: The present study is a retrospective analysis of 2144 patients treated with GNS between January 1997 and December 2011 for trochanteric fractures, classified according to AO classification method. The patients were divided into three groups according to the nailing system: 525 were treated with Standard Gamma Nail (SGN), 422 with Trochanteric Gamma Nail (TGN) and 1197 with Gamma3 Nail. RESULTS: The overall incidence of intra-operative complications was 1.21 %; the incidence of intra-operative complications for each group was 1.71 % for SGN group, 0.47 % for TGN group and 1.25 % for Gamma3 Nail group. The overall incidence of postoperative complications was 5.48 %, and the incidence for each group was 10.73 % for SGN group, 9.92 % for TGN group and 2.92 % for Gamma3 Nail group. CONCLUSION: The GNS is a safe device with a low rate of intra-operative complications. The evolution of this nail system reduces postoperative complications, thus improving the results at follow-up and confirming that the Gamma3 Nail is a safe and predictable device to fix trochanteric fracture.

Bone graft from greater trochanter in posterior wall fractures with impacted fragments.

BACKGROUND: Posterior wall fracture is the most common acetabular fracture. Comminuted fractures with an impacted segment represent a subtype of this injury. The subchondral bone of the articular zone is compressed and causes a bone defect. The impacted fragment should be isolated, mobilized, and then reduced. A bone graft should be used to fill the gap. The other fragments are fixed following the reduction of the impacted segment. MATERIALS AND METHODS: Ten patients with comminuted fractures and impacted segments with bone defects were enrolled in our study, from January 2010 to July 2012. Autogenous bone grafts from the greater trochanter were used to fill the gap in all patients. The reduction was achieved through the insertion of the graft above the impacted fracture, and plate fixation was performed subsequently. Merle d'Aubigne and Postel scoring, modified by Matta, was applied to evaluate the patients during follow-up. The mean follow-up was 12 months. RESULTS: The clinical results included one "excellent", four "very good", four "good" and one "poor". Pain in the zone of graft harvesting was not detected in any patient. Femoral head necrosis was observed in one case. No other severe complications were detected. CONCLUSIONS: Using an autogenous bone graft to fill the bone defect supplies excellent mechanical stability without any severe complications at the donor site. This surgical technique seems to be effective and safe in treating a comminuted fracture of the posterior wall in association with an impacted segment. LEVEL OF EVIDENCE: Level IV.

Multifocal humeral fractures.

INTRODUCTION: Multifocal humeral fractures are extremely rare. These may affect the neck and the shaft, the shaft alone, or the diaphysis and the distal humerus. There is no classification of these fractures in the literature. MATERIALS AND METHODS: From 2004 to 2010, 717 patients with humeral fracture were treated surgically at our department. Thirty-five patients presented with an associated fracture of the proximal and diaphyseal humerus: synthesis was performed with plate and screws in 34 patients, and the remaining patient had an open fracture that was treated with an external fixator. RESULTS: Mean follow-up was 3 years and 3 months. A classification is proposed in which type A fractures are those affecting the proximal and the humeral shaft, type B the diaphysis alone, and type C the diaphysis in association with the distal humerus. Type A fractures are then divided into three subgroups: A-I, undisplaced fracture of the proximal humerus and displaced shaft fracture; A-II: displaced fracture of the proximal and humeral shaft; and A-III: multifragmentary fracture affecting the proximal humerus and extending to the diaphysis. DISCUSSION: Multifocal humeral fractures are very rare and little described in the literature, both for classification and treatment. The AO classification describes bifocal fracture of the humeral diaphysis, type B and C. The classification suggested in this article mainly concerns fractures involving the proximal and humeral shaft. CONCLUSIONS: A simple classification of multifocal fractures is suggested to help the surgeon choose the most suitable type of synthesis for surgical treatment.

[Giant-cell arteritis. Comments on the case histories of 30 patients]. / Arterite a cellule giganti. Riflessioni su una casistica di 30 pazienti.

This survey deals with the main clinical aspects at the diagnosis and during the follow-up of thirty consecutive patients with giant-cell arteritis (temporal arteritis and rheumatic polymyalgia), controlled over a period of 15 years. The work aimed at verifying the diagnostic accuracy with regard to a more underestimated than rare disease. We believe that such a consideration is a useful introduction to a wider research into the epidemiological and biological aspects of the disease which are still to be determined.

[Earthenware and lead poisoning. Description of a case]. / Recipienti di terracotta e intossicazione da piombo. Descrizione di un caso.

A case of acute lead poisoning caused by drinking wine that had been kept in a decorative amphora is reported. Chomico-physical analysis of the internal surface of the recipient evidenced a layer of lead paint very soluble in wine. It is hoped that this report will draw the attention of the practising physician and Preventive Medicine Departments to this unusual cause of saturnism. The craft production of earthenware recipients that have been inadequately glazed and their improper use as containers of drings of foods could be commoner than might be thought on the basis of the sporadic reporting of such cases of lead poisoning.

[Chronic T-cell lymphocytic leukemia: clinical and laboratory aspects of 5 patients]. / Leucemie linfatiche croniche a cellule T: aspetti clinici e di laboratorio di cinque pazienti.

T-cell chronic lymphocytic leukemia: clinical aspects and laboratory findings of five patients. This study illustrates the main clinical aspects and laboratory findings for five patients suffering from T-cell chronic lymphocytic leukemia. They make up 5% of our observations in the Department of Oncology-Hematology at the Busto Arsizio Hospital. Three patients with phenotype CD3+/CD4+ showed a fast course with skin involvement and poor response to chemotherapy (mean survival: 12 months). The course of a patient with unusual phenotype CD3-/CD4+ associated with autoimmune hemolytic anemia and end-stage prolymphocytic transformation was better (survival: 58 months). For 12 years we have been observing a woman suffering from the recently defined CD3+/CD8+/HNK1+ large granular lymphocytes chronic lymphocytosis with associated neutropenia. The disease has good prognosis, with poor symptomatology even without therapy. This study supports the immunological classification of the chronic lymphoproliferative diseases of leukemia and lymphoma with different clinical aspects and prognoses. This method of classification may be important in the consideration of some therapeutical approaches.

[Macrocytosis, megaloblastosis and folate status in chronic alcoholics]. / Macrocitosi, megaloblastosi e stato dei folati negli etilisti cronici.

The figures obtained in simultaneous radioimmunological assays of serum folate and vitamin B12 concentrations and erythrocyte folate concentration in 74 patients are presented. All these patients had a regular daily intake of over 80 g ethyl alcohol and presented an increase in mean blood cell volume. Most of the patients were males hospitalised with liver disease and/or anaemia. All were given bone narrow needle aspirations and liver biopsies. 46% of the patients presented a reduction in erythrocyte folates but vitamin B12 deficiency was rarely encountered. Megaloblastic transformation of the bone narrow was present in 56% of the alcoholics with reduced erythrocyte folates and in 10% of those with normal folate concentration. No correlation was found between serum and erythrocyte folate concentration and degree of liver damage. Serum vitamin B12 levels were higher in patients with cirrhosis. Inadequate diet was frequently found in the alcoholics with reduced folate concentrations. Due to variations in patient selection it is difficult to compare these data with those of other series but they do seem to confirm the hypothesis that the macrocytosis in most "healthy" alcoholics reflects a direct toxic action of the alcohol on erythropoiesis. In contrast folate deficiency is found among "derelict" chronic alcoholics in whom the vitamin deficiency has often not yet produced megaloblastosis of the bone marrow.

[Lack of correlation between HLA haplotypes and familial hypertrophic cardiomyopathy]. / Assenza di correlazione tra aplotipi HLA e cardiomiopatia ipertrofica familiare.

In order to confirm the recent observations of the particular incidence of some HLA antigens in the familial hypertrophic cardiomyopathy we have determined the HLA-A, B and C antigens in the components of a family with high prevalence of hypertrophic cardiomyopathy (10 males and 7 females, age from 10 to 75 years). Six patients were affected by the disease. In one case (sudden death) the diagnosis was established by necroscopy; in the other living subjects by the characteristic echocardiographic features after having ruled out the conditions which can result in secondary myocardial hypertrophy. HLA typing showed the A9, Bw35, Cw4 aplotype in 4 of the 5 living patients affected by hypertrophic cardiomyopathy (2 with obstruction). This aplotype however was not shared by the other patient and was found in one healthy member of the family. Two patients affected by hypertrophic cardiomyopathy without obstruction did not share any aplotype while the 2 subjects with obstructive hypertrophic cardiomyopathy had the same aplotype of a healthy member of the family. Accordingly the genetic study of this family does not allow to establish a steady correlation between hypertrophic cardiomyopathy and HLA aplotypes.

Platelet release reaction and prostaglandin pathway activation in angina patients during exercise: effect of indobufen.

Platelet 14C-serotonin release induced by collagen, and platelet malondialdehyde (M.D.A.) generation induced by thrombin were assessed in twenty patients with stable angina, before and after exercise with a bicycle ergometer. The patients received a single oral 200 mg dose of indobufen or placebo according to a crossover design in double-blind conditions. The M.D.A. concentration increased when exercise was carried out after placebo, whereas indobufen markedly inhibited M.D.A. production and 14C-serotonin release. These results suggest that effort may be an important factor in activation of the platelet prostaglandin pathway and that the use of antithrombotic drugs may be appropriate in patients with angina.

Abnormal platelet function in a case of megakaryoblastic leukaemia.

A platelet function study in a patient with megakaryoblastic leukaemia is reported. The abnormalities of the platelet function suggest a probable platelet membrane injury and a platelet release defect. The reduced platelet half-life and the non changing splenohepatic ratio confirm the clinical and histological features of the systemic disease.

Inhibition of human platelet function by parsalmide.

2-Propargyloxy-5-amino-N-butyl-benzamide (parsalmide), an antiinflammatory drug, inhibits human platelet function in vitro and ex vivo. The degree of inhibition of ADP- and collagen-induced platelet aggregation "in vitro" is dose-dependent and parsalmide shows a more marked effect than equal concentrations of acetylsalicylic acid (ASA) and indometacin. Moreover, malondialdehyde levels in human PRP after addition of thrombin were inhibited at the same degree by parsalmide, ASA and indometacin. In ex vivo experiments, the administration of 400 mg p.o. of parsalmide in arthropathic patients shows a significant inhibitory effect on ADP-induced platelet aggregation at 3 and 24 h after treatment, while a drop of malondialdehyde levels was observed only at 3 h after treatment. No significant inhibitory effect was observed in collagen-induced platelet aggregation.

Daunorubicin and platelet function.

The influence of Daunorubicin on some platelet functions in vitro was investigated, using different concentrations of the drug (0.01-0.02-0.04 microgram/ml). Daunorubicin was shown to inhibit Collagen and Thrombin induced platelet aggregation and the intensity of inhibition on both drug concentration and the time of preincubation. Daunorubicin was also shown to inhibit the release reaction, the platelet prostaglandin pathway and the availability platelet factor 3; the drug at concentrations for clinical use does not damage the platelet membrane, as is the case with the freezing and thawing test, in platelet uptake of 14C-serotonin and as confirmed by the electron microscope. When very high doses (0.16 mg) of Daunorubicin are used, lysis of the platelets can be observed and this is confirmed under the electron microscope by the presence of empty platelets with fractures at the level of the cytoplasmid membrane. Finally, Daunorubicin causes irreversible inhibition of reptilase clot-retraction, even if this is less severe than with Vincristine. Working with gel-filtered platelets, it would appear that the inhibition exercised by the drug on platelet reactions is not caused through modifications in Ca++ metabolism. The authors suggest that Daunorubicin, at the dosages used clinically, induces in vitro thrombocytopathy without damaging the cellular membrane as confirmed by the electron microscope. This impairment of platelet functions could play a part in hemorrhagic diathesis observed during Daunorubicin therapy.