The role of subscapularis repair following reverse shoulder arthroplasty: systematic review and meta-analysis.

PURPOSE: Inadequate subscapularis repair has been advocated as one of the contributing factors for dislocation in reverse total shoulder arthroplasty; nonetheless the need to restore the subscapularis tendon integrity is under debate. The aim of this systematic review was to answer the question: does subscapularis reattachment following reverse total shoulder arthroplasty improve joint stability, range of motion and functional scores? METHODS: The literature was systematically screened in accordance with PRISMA guidelines looking for papers evaluating clinical outcomes of reverse total shoulder arthroplasty in relation to the management of subscapularis tendon. Studies comparing clinical outcomes, complications and dislocation rate with or without subscapularis repair were included. Studies in which reverse total shoulder arthroplasty was performed for trauma or tumors were excluded. The methodology of included articles was scored with MINORS scale and the Risk of Bias was assessed adopting the ROBINS-I (Risk Of Bias In Non-randomized Studies of Interventions) developed by the Cochrane Group. A meta-analysis was also performed combining the studies to increase the sample size and hence the power to obtain meaningful data. RESULTS: The database search identified 1062 records, and 6 full-text articles were finally included. A total number of 1085 reverse total shoulder arthroplasty were assessed on. Except for one study, lateralized prosthetic designs have been used. Dislocation occurred in 0.8% (5/599 patients) of the patient with repaired subscapularis and in 1.6% (8/486 patients) of the tenotomized patients, and subscapularis repair was not associated with a higher risk of dislocation (pooled Peto OR: 0.496, 95% CI: 0.163 to 1.510, p = 0.217). Qualitative assessment revealed no differences in the range of motion and clinical scores. CONCLUSION: Subscapularis repair after reverse total shoulder arthroplasty produces no clinically meaningful benefits, particularly using lateralized prosthetic designs. Subscapularis re-attachment does not improve implant stability, nor increases range of motion or clinical scores. Given these results, keeping in mind the antagonistic effect of the repaired subscapularis on external rotation, no evidence lead to suggest subscapularis reattachment following reverse total shoulder arthroplasty with lateralized prosthetic designs.

Angiosarcoma around total hip arthroplasty: case series and review of the literature.

BACKGROUND: Angiosarcoma (AS) is a rare and malignant tumor which mainly arises in the skin and superficial soft tissue and less frequently in deep soft tissue and bones. Some cases of AS are described in association with vascular and orthopedic devices. Nonetheless, only a few cases of AS around THA are reported in the literature. MATERIALS AND METHODS: We describe five cases of AS arising around total hip arthroplasty who received surgery at our institution (Istituto Ortopedico Rizzoli, Bologna, Italy), and we report the cases described in literature. RESULTS: Foreign bodies such as polyethylene were demonstrated to have a carcinogenic role in animals, but reports of similar cases in humans are rare. Nevertheless, osteolysis induced by wear particles of polyethylene is a frequent event and could induce to desist form considering other more rare causes of osteolysis such as AS. This could be the reason why the diagnosis in several cases was significantly delayed. Common features of these cases could be helpful for doing a prompt diagnosis. The initial presentation is suggestive for septic or aseptic loosening with a massive osteolysis around the cup and/or the stem associated with peculiar aspects as bleeding and loss of weight. Frequently, needle biopsy is negative because foreign-body reaction might have "covered" the most relevant condition of epithelioid AS. CONCLUSIONS: In conclusion in a patient who presents with uncontrollable bleeding, loss of weight and massive osteolysis, AS must be actually considered as possible diagnosis.

Primary malignant myoepithelioma of the distal femur.

A 55-year-old male presented with a 1-month history of localized pain caused by an osteolytic and destructive lesion in the right distal femur. Histologically, the tumour consisted of spindle cells intermingled with epithelioid eosinophilic cells arranged in small cords embedded in a hyalinized-to-chondromyxoid stroma. Electron microscopy and immunohistochemistry showed features of myoepithelial differentiation. RT-PCR failed to demonstrate chimeric transcripts of extraskeletal myxoid chondrosarcoma. The final diagnosis was primary malignant myoepithelioma of bone. The patient is alive with lung metastases 13 months after surgery. Primary malignant myoepithelioma of bone is an exceptionally rare neoplasm that should be considered in the differential diagnosis with the more aggressive myxoid spindle cell sarcomas.

Adjuvant chemotherapy for adult soft tissue sarcomas of the extremities and girdles: results of the Italian randomized cooperative trial.

PURPOSE: Adjuvant chemotherapy for soft tissue sarcoma is controversial because previous trials reported conflicting results. The present study was designed with restricted selection criteria and high dose-intensities of the two most active chemotherapeutic agents. PATIENTS AND METHODS: Patients between 18 and 65 years of age with grade 3 to 4 spindle-cell sarcomas (primary diameter > or = 5 cm or any size recurrent tumor) in extremities or girdles were eligible. Stratification was by primary versus recurrent tumors and by tumor diameter greater than or equal to 10 cm versus less than 10 cm. One hundred four patients were randomized, 51 to the control group and 53 to the treatment group (five cycles of 4'-epidoxorubicin 60 mg/m(2) days 1 and 2 and ifosfamide 1.8 g/m(2) days 1 through 5, with hydration, mesna, and granulocyte colony-stimulating factor). RESULTS: After a median follow-up of 59 months, 60 patients had relapsed and 48 died (28 and 20 in the treatment arm and 32 and 28 in the control arm, respectively). The median disease-free survival (DFS) was 48 months in the treatment group and 16 months in the control group (P =.04); and the median overall survival (OS) was 75 months for treated and 46 months for untreated patients (P =.03). For OS, the absolute benefit deriving from chemotherapy was 13% at 2 years and increased to 19% at 4 years (P =.04). CONCLUSION: Intensified adjuvant chemotherapy had a positive impact on the DFS and OS of patients with high-risk extremity soft tissue sarcomas at a median follow-up of 59 months. Therefore, our data favor an intensified treatment in similar cases. Although cure is still difficult to achieve, a significant delay in death is worthwhile, also considering the short duration of treatment and the absence of toxic deaths.

Resection of malignant bone tumors of the pelvic girdle without extremity amputation.

Fifty-three patients with malignant tumors of the pelvis ossea were evaluated for location of tumor, extent of resection, postoperative function, local recurrence, and survival. Three tumors were unresectable, 17 required a wide local excision, 27 required resection of the hemipelvis without extremity amputation (internal hemipelvectomy), and six required a classical hemipelvectomy with amputation. The incidence of local recurrence was 11.8% for wide local excision, 7.4% for internal hemipelvectomy, and 33% for classical hemipelvectomy. Survival following wide local excision or internal hemipelvectomy was 58% and 41%, respectively, at five years compared with 17% for patients undergoing classical hemipelvectomy. Patients who underwent wide local excision had good to excellent functional results. Patients requiring internal hemipelvectomy initially required ambulatory supports, but many can now ambulate independently, with a neurologically intact extremity, despite a noticeably abnormal gait.

Anterior extraoral surgery to the upper cervical spine.

STUDY DESIGN: A series of 10 patients surgically treated with prevascular or retrovascular extraoral retropharyngeal approach to the upper cervical spine is examined. OBJECTIVES: In orthopedic surgery, retropharyngeal approach may replace the transoral surgery, obviating the risks of infection and the uncomfortable postoperative course of cases in which median labiomandibular glossotomy was used to accomplish complex bone reconstruction. SUMMARY OF THE BACKGROUND DATA: The transoral approach is reported in literature as the classical anterior access to the upper cervical spine that provides direct exposure for anterior decompression of the spinal cord. The risks, the surgical limits, and the postoperative difficulties of transmucosal access suggest the use of an anterior extraoral retropharyngeal approach in orthopedic surgery. METHODS: The series includes four neoplastic lesions (osteoma, aneurismal bone cyst, giant cell tumor, solitary metastasis), three retropharyngeal ossifications resulting from diffuse idiopathic skeletal hyperostosis, and a single case of os odontoideum, craniocervical malformation, and postlaminectomy kyphosis. RESULTS: At follow-up evaluation, all patients achieved a satisfactory outcome, with good clinical and radiographic results; nasotracheal intubation obviated the need for tracheostomy. The wide surgical exposure allowed reconstruction with iliac strut bone grafts and internal fixation in six patients, avoiding the need of a halo device. The only complications were four instances of transient palsies of the marginal mandibular branch of the facial nerve. CONCLUSIONS: In the anterior surgery of the upper cervical spine, the prevascular approach allows a wide surgical exposure, with visualization similar to that obtained with median labiomandibular glossotomy. The retrovascular approach is indicated in selected cases, such as tumor adjacent to the vertebral artery and C1-C2 arthrodesis with bilateral transarticular screws according to Barbour.

Primary chemotherapy and delayed surgery (neoadjuvant chemotherapy) for telangiectatic osteogenic sarcoma of the extremities.

Twelve patients with telangiectatic osteogenic sarcoma (TOS) of the extremities were treated with neoadjuvant chemotherapy, according to two different protocols. Preoperatively the patients received high-dose methotrexate(HD-MTX)/cisplatinum(CPD) or HD-MTX/CPD/adriamycin(ADM). CPD was delivered intra-arterially, the other drugs intravenously. Limb salvage surgery was performed in eight instances and four patients underwent amputation. Post operative chemotherapy was tailored according to the grade of necrosis determined by preoperative treatment on the primary tumor. In ten cases (83%) the grade of necrosis resulted higher than 95%. The mean length of follow-up was 3.5 years with a range of 18 to 72 months. Ten patients (83%) remained continuously disease-free, while two patients developed lung metastases and died of uncontrolled disease. No local recurrences were observed. These results are better than those observed in 167 contemporary cases of conventional osteosarcoma treated with the same protocols. This study confirms that TOS is not always a lethal tumor as suggested by prior reports. Employing neoadjuvant chemotherapy a high percentage of patients with TOS can be cured and in most of them, limb sparing surgery is possible and safe.

Histochemical and ultrastructural study of an elastofibroma dorsi coexisting with a high grade spindle cell sarcoma.

Elastofibroma dorsi is a pseudotumoral fibroproliferative lesion characterized by polymorphic fiber-like deposits of elastinophilic material. Several theories have been reported explaining the pathogenesis of elastofibroma. Recent cytogenetic studies have demonstrated chromosomal instability in elastofibromas, not normally observed in non-neoplastic tissues. These chromosomal defects are commonly observed in aggressive fibromatosis too. Such clinical observations suggest a multistage pathogenetic mechanism for the onset of elastofibroma. This study, using histochemical, immunohistochemical staining techniques, and ultrastructural examination, describes the detection of an otherwise typical elastofibroma contextual to a high grade sarcoma. Hence, the coexistence of elastofibroma and high-grade sarcoma may suggest a causal link between the two pathological entities. The results obtained suggest that the coexistence of the two pathological entities is conceivably coincidental.

Prognostic value of serum alkaline phosphatase in osteosarcoma.

In 163 patients with osteosarcoma of the extremities treated with adjuvant chemotherapy, serum alkaline phosphatase (SAP) levels were evaluated before treatment and successively closely monitored in an attempt to determine whether serum levels of this enzyme had clinical value in predicting the course of the disease. Of 121 patients with elevated preoperative SAP levels, 78 (64%) recurred. Of 42 patients with normal preoperative SAP levels, only 8 (19%) recurred (P less than 0.00001). Of the 140 patients locally treated with amputation, SAP returned to normal values in 77 patients; 46 of these (59%) relapsed. Of the 21 patients whose SAP remained elevated after amputation, all but 2 relapsed (90%). Among 119 patients with normal postoperative values of SAP, at the time of relapse SAP resulted elevated in 22 of 41 patients (53%). These data confirm that in osteosarcoma, preoperative SAP levels have a definite value in establishing the prognosis and that posttreatment follow-up examination should include SAP determination, since persistent elevated or increasing values herald the appearance of a recurrence.

Elastofibroma associated with high grade leiomyosarcoma of the soft tissues: a light and ultrastructural study of one case.

Elastofibroma is a benign lesion occurring almost exclusively in the chest wall, parascapular region being the most frequent site. Rare lesions have been reported in other anatomic locations, but there are no reports about the co-existence of an elastofibroma with a malignant sarcoma. The purpose of the authors is to describe histologically and ultrastructurally the synchronous detection of an elastofibroma and a high grade leiomyosarcoma, speculating on eventual links between the two pathological states.

Extruded cervical disc herniation: treatment with anterior microdiscectomy.

Nine cases of extruded cervical disc herniation (7 with radiculopathy, 2 with acute myeloradiculopathy) were treated by radical anterior microdiscectomy, with opening of the posterior longitudinal ligament, removal of the extruded peridural disc material, bilateral resection of the posterior part of the uncovertebral joints; in 6 cases surgery was completed with Smith-Robinson intersomatic fusion. In all of the cases symptoms rapidly regressed, with considerable neurological recovery. There were no major complications in any of the cases, and 2-5 years after surgery results were evaluated as excellent in 7 cases and good in 2. The use of the operating microscope allows for removal of extruded disc herniations under magnification, in a bloodless surgical field and with no manipulation of the nervous structures. Because of these features, this method is preferred to traditional posterior surgery and anterior surgery without magnification.

Traumatic injuries of the pelvis. SIOT paper 1967.

The paper that Prof. Campanacci read at the Annual Meeting of the Italian Society of Orthopaedics and Traumatology in 1967 was the product of vast research aimed at clarifying and classifying traumatic injuries of the pelvic girdle. The basic idea behind the study was that correct therapeutic conduct cannot neglect an in-depth knowledge of the pathologic anatomy and pathogenesis of the injury. What emerges, in addition to the knowledge of anatomopathology, is the continuing validity of the scientific method with which the problem was dealt with.

Ceramic-ceramic coupling. Total hip arthroplasty in young patients.

Between 1994 and 2000 at the 7th Division of the Rizzoli Orthopaedic Institute a total of 123 total hip arthroplasties were implanted in 105 patients aged under 40 years (mean age 32 years). In most of the cases the patient was affected with osteoarthrosis secondary to congenital hip dysplasia (35%) or osteonecrosis (29%). In all of the cases the same type of cup was press-fitted with alumina on alumina bearing surfaces. The stem was cemented in 4 cases. Six of the patients were submitted to prosthetic revision surgery: 1 as a result of deep infection, 2 recurring dislocation, 3 aseptic loosening of one of the components. Radiographic evaluation did not reveal signs of periprosthetic osteolysis. We did not observe any cases of rupture of the alumina head or any problems related to the modularity of the implant. The authors wish to stress the reliability of using alumina on alumina in a population with high functional demand.

Anterior surgery for the treatment of soft cervical disc herniation.

The authors present the results obtained in a series of 57 cases of soft cervical disc herniation submitted to anterior surgery. The cases included 52 radiculopathies and 5 myeloradiculopathies. Among the radiculopathies, 20 cases were treated by discectomy without magnification, and interbody fusion, and 32 by radical microdiscectomy, completed with interbody fusion in 19 cases and without fusion in 13. The 5 cases of myeloradiculopathy were all treated by microdiscectomy, with fusion in 2 cases and without fusion in 3. The results of treatment of the radiculopathies were evaluated as excellent or good in 80% of the cases treated by "macro" technique, and in 84% of those treated with "micro" technique; in the latter cases, more rapid and complete regression of pain, were always observed probably due to the more radical neurological compression obtained. The 5 cases of myeloradiculopathy obtained excellent results, with evident sensory and motor recovery. Long-term results for cases treated with or without fusion did not differ; the complications observed in the entire series may all be related to use of interbody grafting. The authors conclude that the method of choice in the surgical treatment of soft cervical herniation, with radicular or myeloradicular compression, is radical anterior microdiscectomy without interbody fusion.

Cyst of the medial meniscus: observation of two cases.

The authors report two cases of cyst of the medial meniscus. In both cases imaging diagnostics, CT scan, or MRI allowed us to reveal the characteristic horizontal meniscal lesion that would be the primary cause of cystic degeneration of the meniscus. The two cases were treated by selective resection of the meniscal lesion and arthroscopic decompression of the cyst.

MRI in diagnosis of osteoid osteoma of the proximal femur: a potentially deviating aspect. Description of a clinical case.

Osteoid osteoma constitutes 10-12% of all benign neoplasms of the bone. The tumor more frequently involves the male sex (male to female ratio 2.1:1) and it may be observed in all age groups, with evident predilection for the second decade of life. All of the skeletal segments may be affected, but the most frequent site is the long bones, in the diaphyseal, metaphyseal and more rarely epiphyseal regions. The lesion is characterized by an osteolytic area, the nidus, which is at times partially calcified, surrounded by an osteosclerotic zone that is more or less accentuated. Clinical suspicion and traditional radiography are essential in diagnostic orientation; usually, further imaging methods are also recommended, such as bone scan with Tc99, CT scan and MRI. This last method allows for easy localization of the lesion, although with a sensitivity that is less than that of the CT scan. Nonetheless, the finding, if not supported by clinical suspicion, may be dangerously deviating and it may orient diagnosis towards a more aggressive disease.

Complications in the surgical treatment of lumbar stenosis.

The authors analyze the complications which may occur in the surgical treatment of lumbar stenosis. They report 4 cases of cauda equina syndrome and 8 dural tears in 96 patients aged from 21 to 81 years submitted to multiple bilateral laminectomy. Based on a review of the patients some considerations on surgery for the treatment of lumbar stenosis are discussed. The advanced age of the patients, hypertension, diabetes, vasculopathies in general, severe neurological deficit dating back some time contraindicate surgery. When surgery is indicated a correct preoperative evaluation by MRI from T12 to the sacrum is required to determine the extent of the laminectomy and a safe and accurate intra- and postoperative bleeding control is mandatory. Dural laceration may be repaired by a thoracolumbar fascia patch.

Free microvascular flaps in oncological surgery of the limbs.

Surgery plays a role of primary importance in the treatment of sarcomas of the soft tissues. The first objective of surgical treatment is the local control of the disease. Local recurrence is a serious event, that often requires amputation, and favors metastatic progression of the disease. Currently, except in very rare cases, conservative treatment is the treatment of choice, as it has by now been demonstrated that its results are equivalent to those obtained when demolitive surgery is used. In the distal sites of the limbs, superficial localization of the tendons, ligaments, and joints, the absence of anatomical compartments, make it difficult to perform wide conservative surgery. To this must be added that patients are often sent to see a specialist after a previous inadequate operation, and the presence of a contaminated surgical scar often requires exeresis of a wide area of the skin, sufficient to obstruct healing by primary intention. The use of revascularized free flaps allows for oncologically adequate conservative surgery to be performed, even in anatomical sites where amputation alone traditionally provided a safe surgical margin.

Failed back syndrome: a study on 95 patients submitted to reintervention after lumbar nerve root decompression for the treatment of spondylotic lesions.

The persistence of lumbar and nerve root pain after nerve root decompression surgery may be attributed to one of five causes; 1) progression of the spondylotic disease in the presence of peridural fibrosis; 2) recurrence of disc herniation or new hernia; 3) stenosis of the spinal or nerve root canal; 4) arachnoiditis; 5) vertebral instability. In most patients with peridural fibrosis and worsening of spondylotic lesions regression of nerve root symptoms was obtained after several months of conservative treatment, which continues to constitute essential treatment for most patients with recurrence of lumbar symptoms. The authors report the results obtained with the surgical treatment of 95 patients performed between 1981 and 1991 and divided into the categories listed above. Of these patients, 70 were submitted to further decompression surgery while 25 were submitted to posterolateral vertebral fusion. Reintervention obtained useful results in 83% of the cases where there had been recurrence of disc herniation; nerve root release obtained positive results in 100% of the cases where there was stenosis. Results obtained after wide decompression were poor in all of the cases with arachnoiditis; in these patients conservative treatment with T.E.N.S. can obtain a fair amount of control over pain. Positive results were obtained in 84% of the 25 patients submitted to posterolateral fusion for the treatment of vertebral instability, with fusion obtained in 96% of the cases. Surgical treatment is indicated for psychotic, neurotic patients or those with insurance-related motivations only when the organic cause of the symptoms is clearly evident.

Differential diagnosis of low back pain.

Low back pain is a symptom common to many vertebral and extravertebral affections. The origin of low back pain mostly derives from a pathology localized in the spine, as in the case of degenerative lesions, neoplastic lesions, infections, fractures, metabolic diseases such as osteoporosis, or more rarely, rheumatological diseases. The causes of extravertebral low back pain may be renal, pancreatic, gastrointestinal, or of the female genital apparatus. The authors present a series of clinical aspects which must always be taken into consideration in order to avoid errors in the diagnosis and evaluation of a patient with low back pain.